9
Inspections
2
Deficiencies
0
Actual Harm or Above
13
Occurrences
April 16, 2026
Last Inspection
S/S A/B Minimal potential
The most recent inspection of SUNRISE OF WESTMINSTER on record is dated April 16, 2026. Across 9 published inspections, state surveyors cited 2 deficiencies, none of which reached the actual-harm level.
Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.
Provider Information
Status
Active
Facility Type
Assisted Living Residence (Licensed Only)
Administrator
Archibald, Angela
Owner
SZR SECOND WESTMINSTER ASSISTED LIVING LLC
Phone
(303) 410-0500
Payor Source
Private Pay
City
WESTMINSTER
ZIP
80020
Inspections & Citations
9 inspections · 2 deficiencies4/16/2026Licensure (Re-licensure) · ID 05GO11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
An administrative relicensure survey was completed on 4/16/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
3/26/2026Licensure Complaint · ID KLYQ111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO40720 was completed on 3/26/26. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1632Med/Med Adm-Med Strge LckdS/S B▼
Findings
Based on observations, interviews, and record review, the residence failed to ensure medications were stored in a locked cabinet, cart, or storage area when unattended by qualified medication administration persons (QMAP) or other licensed staff, affecting 3 out of 7 sample residents (#5-#7). Findings include:Residence Policy:The Medication Oversight Program policy, dated 4/20/23, read in part, "Prescription and over the counter medications are stored as follows: All medications are secured in a locked medication cart or other container/area that is locked." ObservationsObservation on 3/26/26 revealed unsecured over-the-counter medications in resident rooms unattended by QMAPs. In Resident #6's room there were capsules of Tylenol Extra Strength 500 mg observed on the bedside table. In Resident# 5's room there were capsules of Benadryl Liquid 25 mg, which were observed unsecured in the bathroom cabinet. Resident #7 had a bottle of Pepto Bismol 262 mg located in an open basket in her bathroom. Record reviewA care plan dated 12/9/25 for Resident #5 read in part, staff was required to administer Resident #5 medications. A written practitioner's order for Resident #6, dated 6/4/25, directed the residence to administer acetaminophen (Tylenol) 500 mg as needed every 8 hours. However, the order did not explicitly read the resident was able to self administer the medication. The Resident Agreement/Service Level Documents, dated June 2025, for Resident #7 read the residence staff was responsible for medication administration and oversight. InterviewsOn 3/26/26 at 9:15 a.m., the administrator stated over the counter medication was managed by staff unless there was a practitioner order stating otherwise. The administrator reviewed the medications that were found in Resident #5-#7's rooms and confirmed the residents did not have orders that allowed self administration of medications and they should not have been in their rooms. On 3/26/26 at 1:10 p.m. the administrator stated that if the residence was providing medication administration and there was no order for bedside medications, she expected there not to be medications in residents ' rooms and stated residents having medications in their rooms did not meet her expectations.
Plan of correction · submitted by the facility
On 3/26/26 the community immediately removed the medications identified to be without matching physician orders for self-administration from the rooms of residents 5, 6, and 7. On 3/26/26, at a scheduled Medication Care Manager Meeting, the Resident Care Director reeducated the medication care managers on proper medication storage and the requirements for self-administration of medications. On 3/26/26, at a scheduled Town Hall Meeting, the Executive Director (ED) reviewed the survey and citation, and the Resident Care Director reeducated the team members on proper medication storage and the requirements for self-administration of medications. On 3/27/26 and 3/30/26 room checks were conducted by the Resident Care Director and Assisted Living Coordinator to ensure all medications were stored properly. On 3/30/26 Executive Director sent communication to families to remind them of proper medication storage policies and procedures to include use of OTC medications without a matching physician order for self-medication. On 4/8/26, at the Quarterly QAPI meeting, Executive Director reviewed the survey results and citation and re-educated the coordinator team on regulation 6 CCR 1011-1 Chapter 7 - Assisted Living Residences Part 14 - Medication and Medication Administration - Medication Storage. Beginning the week of 4/13/26 and ongoing for 3 months, the Resident Care Director and Assisted Living Coordinator will audit rooms once monthly to ensure all medications are stored properly and no medication is kept at resident bedside without a matching physicians order. On 7/8/26 and ongoing, This Plan of Correction will be discussed and evaluated quarterly for two quarters by the ED and Coordinators at the Quality Management (QAPI) meeting to verify it is still effective If not effective, it will be amended and a new POC and training will be implemented and monitored to verify the violation does not occur.
7/29/2025Licensure Complaint · ID EI8911No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO39216 was completed on 7/29/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
8/1/2024Revisit: Licensure Complaint · ID TBZS12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 8/1/24 for all previous deficiencies cited on 3/5/24. 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.
3/5/2024Licensure Complaint · ID TBZS111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO35044, was completed on 3/5/24. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1634Med/Med Adm-Med Strge Dbl LckdS/S A▼
Findings
Based on record review and interview, the residence failed to ensure two individuals jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting two of six controlled substance log books. Findings include:1. Residence PolicyThe residence's Medication Oversight Program, dated April 2023, read in part, " All controlled substances are counted at the beginning and ending of each shift ... Both team members sign the controlled substance count log in the appropriate box after verifying accuracy of drugs."2. ObservationThe residence had two separate buildings: Sunrise Villa and Mountain Villa. The residence had a total of six medication carts, each with one controlled substance log book. 3. Record ReviewStaff #3 was the qualified medication administration person (QMAP) who was assigned to count the controlled substance lists in the Mountain Villa building. The two controlled substance log books did not include Staff #3's incoming signatures and only included Staff #4's outgoing signatures. 4. InterviewsOn 3/5/24 at 8:39 a.m., Staff #3 said she forgot to sign the controlled substance log books at the time she counted controlled substances with Staff #4 the morning of the onsite investigation. On 3/5/24 at 8:40 a.m., the resident care director said she expected both QMAPs to sign the controlled substance log books. On 3/5/24 at approximately 3:00 p.m., the administrator said he expected the QMAPs to sign the controlled substance log books immediately after the medications were counted.
Plan of correction · submitted by the facility
Immediate Solution: With respect to the specific resident/situation cited.-Immediately conducted a thorough internal audit to identify any further discrepancies or oversights in medication management protocols on 3/5/2024 and 3/6/24.-Implemented enhanced training sessions for staff members focused on accurate documentation procedures and double-check protocols to prevent similar errors in the future on 3/8/2024Expand Scope: With respect to how the facility will identify residents/situations for the identified concerns.- Narcotic sign-off sheets were audited daily for 3 days 3/6/2014 to 3/8/2024 by Resident Care Director or designee.-Narcotic sign-off sheet audit conducted weekly by nurse for the four weeks following to conclude 4/6/2024.- Identified issues will be immediately reported to the licensed nurse and correction will be made in a timely manner. Systemic Change: With respect to what systemic measures have been put into place to address the stated concern- Medication managers conduct weekly audits to ensure accuracy and adherence to protocols.-Monthly audits by a nurse to provide an additional layer of oversight and accountability in the medication management process, specifically focusing on narcotic sign-off sheets.-Instituted quarterly audits of narcotic sign off sheets by Executive Director (ED) and Resident Care Director (RCD) during medication cart audits to reinforce the importance of proper documentation and to identify any systemic issues that require corrective action. Monitoring: With respect to how the plan of correction will be monitored- RCD will confirm results of the weekly audit and present them at Quality Assurance and Improvement (QAPI) Meetings for the next three months.- During and at the conclusion of the 3 months, the QAPI team will re-evaluate and initiate any necessary action or extend the review period.- The Executive Director/designee is responsible for confirming implementation and ongoing compliance with the components of this Plan of Correction and addressing and resolving variances that may occur.
1/8/2024Licensure Complaint · ID Y7TX11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO34586, was completed on 1/9/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9/7/2023Licensure and Licensure Complaint (Combined) · ID 3EXG11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaints #CO30298, #CO30300, #CO30496 was completed on 9/7/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9/7/2023Revisit: Occurrence Survey · ID B8S412No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure revisit was completed on 9/7/23 for the previous deficiency cited on 7/8/2020. The residence is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
9/7/2023Revisit: CHOW and Licensure Complaint (Combined) · ID OY4X12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure revisit was completed on 9/7/23 for all previous deficiencies cited on 9/16/2020. The residence is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
Reportable Occurrences
13 records6/10/2026Misappropriation of Property · ID 2623R753005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 6/11/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Adult Protective Services (APS) alerted the facility that client (A) experienced financial exploitation. Client (A) reported that their representative stole $200,000 from them. During the course of the investigation, the healthcare entity ensured client (A) felt safe, contacted police, reviewed records, and conducted interviews. Record review revealed inconsistent rent payments by the representative. APS investigated the incident, which remained ongoing. The facility and APS collaborated on finding client (A) a new representative to assist with their finances. The facility confirmed they would notify APS if the representative visited client (A). The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 7/13/2026 · released to the public 7/21/2026.
3/27/2026Physical Abuse · ID 2623R753003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/27/26, 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 (B) hit client (A) on the arm with a closed fist. During the course of the investigation, the healthcare entity separated both clients, contacted police, and conducted interviews. No visible injuries for client (A) were indicated when assessed. Due to cognitive impairment, both clients were unable to provide detailed information about the incident. The facility implemented a 1:1 caregiver for client (B), de-escalation techniques to promote space, and contacted their medical provider, who treated an infection. The facility implemented separate seating for both clients. 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 5/12/2026 · released to the public 5/19/2026.
2/3/2026Physical Abuse · ID 2623R753002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/3/26, 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 overheard staff (1), who was a hospice caregiver, being verbally aggressive outside client (A)'s room. Client (A) reported that staff (1) used foul language, poked and pushed their arm, and threw their emergency call button across the room. During the course of the investigation, the healthcare entity ensured staff (1) was no longer at the facility, contacted police and the hospice provider to report the incident, and conducted interviews. Staff indicated no visible injuries were observed, and client (A) denied having any current pain. Staff (1)'s employment was terminated by the hospice provider, and a new hospice staff member was sent to provide care for client (A). Due to the alleged event being unwitnessed and no visible injuries or complaints of pain, 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 3/27/2026 · released to the public 4/3/2026.
10/20/2025Physical Abuse · ID 2523R753006Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/20/25, 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. Staff (1) observed Client (B) in Client (A’s) room. Client (A) was in bed when Client (B) struck Client (A’s) leg with an open hand over the covers. During the course of the investigation, the healthcare entity notified the police, family and ombudsman, conducted interviews and record review. The client’s were separated and Client (B) was placed on frequent checks. Client (A) was assessed. No pain or injury was found. To prevent a recurrence, staff members coordinated with Client (B’s) family and physician to develop a plan to address the new concern of physical aggression. Client (B) continues on frequent safety checks in the evenings and overnight when the Client (B) tends to be more agitated. Staff are to assist Client (B) in peer-to-peer conversations and activities such as folding laundry. 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’s occurrence report was submitted within the required timeframe.
Publication
Sent to facility 5/11/2026 · released to the public 5/18/2026.
9/15/2025Physical Abuse · ID 2523R753005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/15/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (B) kicked Client (A) twice in the leg after Client (A) sat down at the same table. Client (B) also made a verbal threat towards Client (A). During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) was assessed by their medical provider and had no visual injuries. Both clients had a cognitive disability and could not recall the incident. Staff will take Client (B) on a walk or participate in redirection techniques when they are frustrated. Staff will provide a quiet environment to reduce frustration with clients. The incident was witnessed 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.
Publication
Sent to facility 1/28/2026 · released to the public 2/4/2026.
7/5/2025Physical Abuse · ID 2523R753004Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/10/25, 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 help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed client (A) with their hands around the neck of client (B), and client (B) alleged they were also hit by client (A). During the course of the investigation, the healthcare entity separated the clients prior to notifying law enforcement, reviewed medical records, and conducted interviews. The event started because client (B) wandered into client (A)’s room while they were resting. The facility updated client (B)’s care plan related to wandering interventions, updated client (A)’s care plan related to monitoring of mood and getting staff assistance if someone is in the room, and educated staff. While physical contact did occur, it did not result in visible injuries or reported pain. 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 not submitted within the required timeframe.
Publication
Sent to facility 11/20/2025 · released to the public 11/27/2025.
3/14/2025Misappropriation of Property · ID 2523R753003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 3/19/25, 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. Client (A) alleged they were missing 10 rings. During the course of the investigation the healthcare entity conducted a search, and interviews. Staff indicated the client's story changed multiple times and their room was usually cluttered. The police were notified and no assailant was identified. Client (A) was educated to utilize their lock box for their valuables. The lock was changed and the client was given a key and the administrator. 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 8/21/2025 · released to the public 8/28/2025.
2/3/2025Diverted Drugs · ID 2523R753002Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 2/4/25, 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 help prevent a future recurrence. The healthcare entity reported diverted drugs. The facility was notified by law enforcement that medications that were supposed to be destroyed were found in the room of a client. During the course of the investigation, the healthcare entity suspended the staff involved, partnered with the pharmacy for a full medication cart audit, conducted interviews, and provided immediate training to all staff. The staff involved was terminated, arrested, and admitted to taking 13 discontinued medications that belonged to 13 clients. The clients were not harmed and received all required medications. The facility educated staff, implemented a new medication disposal procedure, changed the locks to medication storage areas, and refreshed weekly and monthly cart audits. 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.
11/14/2024Neglect · ID 2423R753004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 11/14/24, 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 neglect of a client. A family member of the client alleged the client had been neglected, but did not give details before the client had gone to the hospital. During the course of the investigation the healthcare entity conducted interviews, reviewed documentation and assessed the client. The client had an infection that was treated in the hospital, before going to a rehabilitation facility for a few days. It was not determined when the client had symptoms of the infection and it was possible they had it before being admitted to the facility. There was no evidence the client had been neglected. The client returned to the facility with new orders that were implemented. Staff continued to encourage the client to be active in their care. Staff were educated again on methods for communication, infection symptoms, and met with the family to ensure the clients plan of care was accurate. 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 7/17/2025 · released to the public 7/24/2025.
10/19/2024Misappropriation of Property · ID 2423R753003Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 10/18/24, 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 a staff member lost their gold coin. The client had a gold coin in their possession and did not describe any staff members. The client was encouraged to use their lock box, or a safe at the bank. The police were notified and no assailant was identified. 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 3/24/2025 · released to the public 3/31/2025.