ELK RUN ASSISTED LIVING COMMUNITY

SUMMARY OF FINDINGS:On 11/10/25, 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 neglect of a client. Staff #1 allegedly did not follow Client (A)’s plan of care when transferring the client, causing injury to Client (A). Diagnostic testing later confirmed the presence of an ankle fracture. During the course of the investigation, the healthcare entity suspended Staff #1, notified law enforcement, and conducted interviews. Staff #1 reported Client (A)’s foot became entangled during a transfer. Client (A)’s interview corroborated Staff #1's statement. Per the facility’s investigation, Staff #1 admitted to not having read or followed the client’s care plan and performed an incorrect transfer. It was then determined that Staff #1 did not report the client’s change of condition, which was discovered the following morning by another staff member. Staff #1 did not follow facility protocol by reporting or documenting the incident. Client (A)’s care plan was updated based on current transfer status. All staff were re-educated on reading care plans and on protocols for reporting incidents. Therapy services provided demonstrations of appropriate transfer techniques to reduce the risk of recurrence among all clients. 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 2/2/2026 · released to the public 2/9/2026.

SUMMARY FINDINGS: On 4/3/24 resident (A) alleged staff member (1) was physically abusive with her and when interviewed stated they were sexually intimate. No findings when a physical assessment was completed on resident (A). Staff member (1) was placed on leave and staff notified the police. The police interviewed resident (A) and she stated she made everything up for attention and was joking. Staff member (1) denied the allegations and stated they were assisting staff member (2) with resident (A). Staff member (2) denied the allegation as well. The family member of resident (A) stated resident (A) had a history of making up stories for attention. The facility investigation was not substantiated due to the many different stories and admitting to making up the allegation for attention. To help prevent a recurrence, staff were to provide care for resident (A) in pairs of two. Resident (A) will continue receiving additional support from hospice with a one-to-one volunteer. 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 12/9/2024 · released to the public 12/16/2024.

DESCRIPTION OF OCCURRENCE: On 2/20/24, four residents (A, B, C, D) alleged resident (E) yelled, pointed her finger and talked to them in a threatening manner. All four residents stated they were fearful. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, and ombudsman. All residents were separated. Resident (E) admitted her approach could be different. The facility investigation concluded all residents stated the same, they were in fear. To help prevent a recurrence, resident (E) was educated on communicating with other residents, will take a class on boundaries, and staff will check in with resident (E) for support since she is the resident council president. 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 12/2/2024 · released to the public 12/10/2024.

DESCRIPTION OF OCCURRENCE: On 10/20/23, the son of a deceased female resident (A) in her 70s reported on a social media platform that the rings from his mother were stolen from her dead body. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and third party agencies. Multiple interviews were conducted. The husband of resident (A) stated he saw the ring on the night of 10/10/23. The hospice nurse stated after the resident passed, during the post mortem care, there was no ring. The mortuary indicated they did not have the rings. The contractor for the mortuary stated they removed the rings and left them on the bedside table and told staff member (1). There was no documentation to prove this occurred. Staff member (1) stated he was never told about any rings. The son indicated the contractor never got permission to remove the rings. This information was all provided to the police. The facility investigation concluded a police case was still pending. To help prevent a recurrence, the facility informed hospice, the nurse needed to be present throughout the postmortem process. The contractors were notified they were not to remove any items unless permitted and to physically give it to staff to lock and keep safe. 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 9/30/2024 · released to the public 9/30/2024.