LAKEWOOD RESERVE

SUMMARY OF FINDINGS:On 3/26/25, 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) alleged they were assaulted by Staff #1 but unsure of when it occurred. During the course of the investigation the healthcare entity ensured Client (A) and the alleged assailant (staff #1) were separated before the police were notified. Client (A) had old bruising on both shins. Staff #1 denied the allegation and stated they never assisted the client as alleged. Staff #1 mainly worked on another side of the facility. Client (A) does have cognitive impairment with confusion. Moving forward, Staff #1 will not be scheduled to work on the memory care side of the facility. Training was reinforced with staff regarding signs of abuse. 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 8/26/2025 · released to the public 9/2/2025.

SUMMARY OF FINDINGS:On 3/20/25, 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. The facility was made aware of an allegation of Staff #1 holding Client (A) down. During the course of the investigation the healthcare entity ensured Client (A) and the alleged assailant (staff #1) were separated before the police were notified. Client (A) could not be interviewed due to cognitive impairment. No visible injuries. Camera footage was reviewed and it was determined Staff #1 was overly aggressive with Client (A). Staff #1’s employment was terminated. 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 8/26/2025 · released to the public 9/2/2025.

SUMMARY OF FINDINGS:On 2/27/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client had a fall and hit their head before being diagnosed in the hospital with several brain bleeds and a possible stroke. The client’s care plan will be updated to reflect safety interventions should they return to the facility. 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 4/10/2025 · released to the public 4/17/2025.

SUMMARY OF FINDINGS:On 2/25/25, 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. During the course of the investigation the healthcare entity conducted a search, reviewed camera footage and interviews. The police were notified and no assailant was identified. The family could not determine if the item was consumed or missing. The next item will be placed in the medication cart for sight to monitor. The family was made aware of this information. 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 4/20/2025 · released to the public 4/27/2025.

SUMMARY OF FINDINGS:On 2/2/24, 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 misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, and interviews. The client alleged two rings were missing. The police were notified and no assailant was identified. The client was provided with a lock box for their valuables. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 4/1/2025 · released to the public 4/8/2025.

SUMMARY OF FINDINGS:On 1/19/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, and interviews. The client alleged some items were taken from their car but could not provide any details. The police were notified and no assailant was identified. The client was educated to use their locked cabinet in their room to secure items. 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 4/1/2025 · released to the public 4/8/2025.

SUMMARY OF FINDINGS:On 1/16/25, 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. During the course of the investigation the healthcare entity ensured the client felt safe. The investigation revealed Client (A) alleged Staff #1 threatened them and said they would call the police on them. There were no witnesses the the allegation, Staff #1 denied the allegation of aggression or yelling, but stated they did tell Client (A) they were going to call the police. Staff #1 thought they were both joking in their interaction. Client (A) refused to be a part of the investigation. Staff #1’s employment was later terminated due to concerns not related to this incident. 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 8/1/2025 · released to the public 8/8/2025.

SUMMARY OF FINDINGS:On 1/10/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, and interviews. The client is unsure if they misplaced the item or someone stole it and wanted to make a report. The police were notified and no assailant was identified. The client was offered a lock box for their valuables. 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 4/1/2025 · released to the public 4/8/2025.

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 misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, interviewed others, review the camera footage and offered the client a lock box. The police were notified and no assailant was identified. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 2/27/2025 · released to the public 3/6/2025.

SUMMARY OF FINDINGS:On 10/24/24, 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 verbal abuse of a client. Client (A) indicated they were fearful of Staff #1. During the course of the investigation the healthcare entity ensured the client felt safe, suspended Staff #1 and conducted interviews. The investigation revealed multiple clients expressed Staff #1 yelled at them during care and services making them fearful. Staff #1’s employment was terminated. 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 7/5/2025 · released to the public 7/12/2025.

SUMMARY OF FINDINGS:On 10/7/24, 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. The staff heard yelling and arrived at Client (A)’s room. Client (A) indicated Client (B) forced their way into their room and proceeded to punch them before they fought back. Client (A) was assessed by the paramedics without injuries. Client (B) has cognitive impairment and could not recall what happened. Client (B) was moved to a memory care setting and provided a higher level of care. Staff will continue to monitor 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.

Sent to facility 5/30/2025 · released to the public 6/6/2025.

SUMMARY OF FINDINGS:On 8/25/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported verbal abuse of a client. During the course of the investigation the healthcare entity ensured the clients felt safe. The investigation revealed Staff member (1) was alleged to be intoxicated and verbally abusive with threats regarding care for Client (A). Witnessed by other staff. Staff member (1) left the facility before management arrived and was suspended before having their employment terminated. 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 5/22/2025 · released to the public 5/29/2025.

SUMMARY OF FINDINGS:On 8/28/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted interviews and provided the client with a camera to use in their apartment. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

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

SUMMARY OF FINDINGS:On 8/13/24, 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 misappropriation of client property. During the course of the investigation the healthcare entity reviewed camera footage, and made sure the client felt safe. 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 2/6/2025 · released to the public 2/13/2025.

SUMMARY OF FINDINGS:On 7/28/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity suspended staff member (1), conducted interviews, offered reassurance and education on safety to the client, and the use of a lock box for her valuables. 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 2/26/2025 · released to the public 3/5/2025.

SUMMARY FINDINGS: On 7/3/24 Resident (A) reported to management two bottles of wine were stolen from her refrigerator. Resident (A) was unsure of when they went missing. The staff notified the police. The facility investigation concluded, no assailant was identified. No other residents reported missing any items. It was discovered Resident (A) was leaving her door propped open during the night. To help prevent a recurrence, cameras were installed with the residents permission. Resident (A) was asked to close her door going forward at night and to lock it when she was not in her room. 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.

Sent to facility 1/30/2025 · released to the public 2/6/2025.

SUMMARY OF FINDINGS:On 6/11/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported 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 Client (A) punch Client (B) in the stomach and shoved him. No visible injuries, however both clients have cognitive impairment and could not recall the incident. Client (A) was provided with one-to-one oversight while awake. 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 3/26/2025 · released to the public 4/2/2025.

SUMMARY OF FINDINGS:On 5/29/24, 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. The staff witnessed Client (A) slap Client (B) twice. Reddened areas seen to Client (B). One-to-one staff and family monitoring for Client (A) as it was indicated tooth pain may have been a cause of his physical aggression. Client (A)’s pain was addressed. Both clients have cognitive impairment and will be kept apart. 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 3/26/2025 · released to the public 4/2/2025.

DESCRIPTION OF OCCURRENCE:On 4/30/24 the facility submitted a neglect report for an alleged incident that occurred back on 4/13/24. A family member of resident (A) reported the resident had been neglected. The family member visited the resident and found their bed sheets stained with feces and the recliner s/he was sitting on was soaked with urine. The family member alerted staff and staff came to clean it up. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family/guardian, ombudsman and physician. From documentation review, the resident was independent with care needs and only required assistance with medications. A care conference for resident (A) was held on 4/20/24 to discuss the resident’s increased care needs. An administrative staff spoke to the family member about the incident, and updated the resident’s care plan to include toileting assistance every four hours during waking hours, and laundry services on an as needed basis. A urinalysis was completed and revealed the resident had a urinary tract infection. The facility began administration of an antibiotic on 4/29/24. During interview, Resident (A) stated s/he was drinking too much diet soda and was having bowel incontinence. The resident did not report neglect, felt safe in the residence and knew s/he needed to be there. Two staff stated that on the morning of 9/13/24, they had checked on resident (A) and found them asleep in bed. The resident was subsequently administered medications at 9:18 a.m. and during both of these encounters; the staff did not detect incontinence. A housekeeper confirmed s/he had cleaned the resident’s apartment following the report of the family member, and said it was not normal for resident (A) to be incontinent. From the investigation, the facility concluded staff were following the care plan for Resident (A) and their needs had suddenly changed, due to a urinary tract infection and incontinence. The resident’s care plan was updated, prior to the resident’s move from the residence on 5/4/24. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The agency/facility's response to this occurrence violated licensing standards by failing to report the occurrence within the required timeframes.

Sent to facility 11/15/2024 · released to the public 11/22/2024.

SUMMARY FINDINGS: On 4/23/24 resident (A) with cognitive impairment was able to get out of the facility by pressing the bar on the door. He then went through the courtyard gate as well with the alarm sounding. Resident (A) was found by the police a little later about a fourth of a mile away. Resident (A) was returned to the facility without any injuries and provided a one-to-one staff member for safety concerns. Staff did not locate anyone at the alarmed door. The facility investigation concluded resident (A) left the facility after having some difficulty sleeping. He had no prior attempts to leave the facility. Staff have increased safety checks with him and his physician will review his medications for any necessary adjustments. Audible alarms for the exit doors were adjusted. 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 11/26/2024 · released to the public 12/3/2024.

DESCRIPTION OF OCCURRENCE:On 4/28/24, resident (A) reported that a bottle of clonazepam was missing. S/he believed it might have disappeared on April 15, 2024, from a broken lock box stored in their room. Resident (A) managed their own medication administration independently and did not require assistance from facility staff. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family/guardian, and physician. A new lock box was provided to resident (A). During interviews, resident (A) said she did not know how the medication went missing. Staff were unaware that the medication was missing. Since the new lock box was provided, resident (A) has had no further incidents of missing medication. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The agency/facility's response to this occurrence violated licensing standards by failing to report the occurrence within the required timeframes.

Sent to facility 11/15/2024 · released to the public 11/22/2024.

DESCRIPTION OF OCCURRENCE: On 4/11/24, resident (A) reported 12 prescription pain pills, oxycodone missing from his file cabinet. Resident (A) alleged the clasp was pried off the cabinet and the medications were stolen. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police. Resident (A) had covered the camera in his room with a paper cup and incident wasn't captured on video. The facility cameras didn't capture anyone entering the resident's room. Resident (A) opted to keep his medications and self administer until the new lock box arrived. Resident (A) managed his own medications. The facility investigation concluded no assailant was identified. It was unknown if anyone else entered resident (A)’s room. To help prevent a recurrence, resident (A) removed the remainder of the medication from the cabinet he made and the facility ordered him an official lox box for his medications. Resident (A) will place the box in place out of sight. 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 11/21/2024 · released to the public 11/28/2024.

DESCRIPTION OF OCCURRENCE: On 3/23/24 a resident was taken to the other side of the facility to participate in an activity requested by her daughter. Resident (A) left the facility and could not return. The police escorted her back to the facility from a restaurant she had previously walked to with friends before her cognitive decline. Resident (A) was identified as being at risk. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. After resident (A) returned to the facility, she was immediately moved to a secure memory unit after discussion with family, the resident and her physician. The family has decided to move resident (A) out of the facility. The facility investigation concluded resident (A) did not wait for staff to escort her back to her side of the facility and left the facility without staff being aware. To help prevent a recurrence, resident (A) was provided safety oversight until the family moved her out of the facility. 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. However, the licensing standard for timely reporting was not met.

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

DESCRIPTION OF OCCURRENCE: On 3/8/23 the facility was made aware by the daughter of a male resident (A) in his 80s that $86.00 dollars was missing from his wallet, last seen on 3/4/23. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, and families/guardians. Staff helped resident (A) search for the money. The money was not located. The key entry log was audited and did not indicate that any staff member had entered the residents room during the alleged date. The daughter stated resident (A) may be confused because the details would change. The facility investigation concluded after interviews with staff and family, no assailant could be identified. However, resident (A) was reimbursed the money from the facilities account. To help prevent a recurrence a sign was placed on resident (A)’s door to notify staff not to enter resident (A)’s room unless he was in the room. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 7/26/2023 · released to the public 8/2/2023.

DESCRIPTION OF OCCURRENCE: On 1/26/23 a female resident in her 70’s was found on the floor by a staff member. She was awake and alert and a bump was observed on her head. 911 was immediately called to transport the resident to the hospital for further evaluation and treatment. AGENCY/FACILITY ACTION: The facility conducted an internal investigation and notified the police, physician, family/guardian, ombudsman and APS (adult protective services). Staff remained with the resident and provided comfort while awaiting the ambulance to arrive. The facility was later informed that the resident had been diagnosed with a brain bleed. She was admitted to the hospital for closer monitoring and treatment and then discharged back to the facility on hospice care. The report documented that the resident was assessed to have a cognitive deficit. She required two person assistance and she did not have a history of known falls. Safety interventions were in place at the time of the event. The facility concluded that the resident experienced an unfortunate, unwitnessed fall with injury due to attempting to self transfer. A meeting was held with the facility and the resident’s spouse to discuss the residents care needs. The facility provided additional information following the submission of this final report. They said that additional interventions put into place to prevent a recurrence included educating the resident, spouse and staff regarding fall safety and precautions. Additional supervision was provided to the resident after her readmission. The resident subsequently discharged from the facility to a group home for a higher level of monitoring and care. 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 7/17/2023 · released to the public 7/24/2023.

DESCRIPTION OF OCCURRENCE: On 1/10/23 management was made aware by a written statement that a male resident (B) in his 70s had punched a male resident (A) on 1/8/23 and resident (A) in his 90s was afraid resident (B) was going to kill him. The incident was witnessed by a qualified medication administration person (QMAP) (1). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians, Adult Protective Services and ombudsman. Both residents were separated and taken to their apartments. The police came to the facility and made a report. Both residents were assessed without any visible injuries. Resident (A) appeared to be in good spirits after the event. Resident (B) stated he thought resident (A) was “trying to kill” him. Both residents have cognitive impairment. No documentation to indicate a pattern of behaviors. The facility investigation concluded the incident was witnessed by staff and no further alterations or issues. To help prevent a recurrence resident (B)’s medications were reviewed by his physician to any necessary adjustments that were needed. Both residents will be monitored by staff for 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 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 7/24/2023 · released to the public 7/31/2023.