MORNINGSTAR AT BEAR CREEK

SUMMARY OF FINDINGS:On 10/18/25, 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 physical abuse of a client. Staff (1) heard loud vocalizations and entered the hallway. Staff then observed Client (A) standing near Client (C)'s door with blood on their left hand. Client (B) was on the ground and Client (C) was standing in the hallway. A shattered wine glass was on the floor and wine was splattered on Client (A)'s shirt and door. Client (A) and Client (B) were redirected into different areas of the facility and Client (C) was assisted into their room locking the door at their request. Increased safety checks were implemented. During the course of the investigation, the healthcare entity notified the police, family, physician and Adult Protective Services (APS). The Clients were assessed for injuries. Client (A) had a laceration to their left middle finger. First aid was provided. No injuries were observed on Clients (B or C). Documentation was reviewed and interviews were conducted. Due to their cognitive abilities, the clients were not able to provide information into what happened. However, Client (C) stated they preferred to have their door locked and did not like "unwelcomed visitors." To prevent a recurrence, the healthcare entity moved both Client (A)'s and Client (C)'s rooms to opposite ends of the facility. Client (C)'s physician was to evaluate for medication or alternative interventions. 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.

Sent to facility 5/18/2026 · released to the public 5/25/2026.

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 prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff witnessed Client (B) holding the wrist of Client (A), before Client (A) complained of thumb pain and redness was seen. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. An additional bruise was seen to Client (A)’s wrist. Client (A) recalled the incident, however, Client (B) did not. Increased safety checks, including in common areas, redirection of the clients, and medication review to assist with negative behaviors was implemented. 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 3/9/2026 · released to the public 3/17/2026.

SUMMARY OF FINDINGS:On 10/1/25, 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. Video footage revealed Client (B) struck client (A) with a shoe before Client (A) fell to the floor sustaining a scratch to their forehead. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Both clients have cognitive impairment, however, Client (B) stated they should be able to remove individuals from their room. Frequent safety checks were implemented, Client (B)s door was locked to prevent others from entering, and discussions of a room change for 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.

Sent to facility 3/9/2026 · released to the public 3/17/2026.

SUMMARY OF FINDINGS:On 9/26/25, 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 help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Reportedly, client (A) grasped client (B)'s arm and would not let go despite staff's verbal re-direction. In response, client (B) struck client (A)'s arm with a closed fist resulting in client (A) releasing their grip. During the course of the investigation, the healthcare entity separated the clients, increased safety checks, assessed clients for injury, conducted interviews, and contacted police. No visible injuries were observed with either client when assessed; however, client (A) expressed being angry and frustrated post the incident. Due to a cognitive impairment, neither client could provide additional insight into what triggered the aggressive act. Staff reported it appeared client (A) wanted client (B)'s attention and client (B) did not care for client (A)'s physical touch. The facility adjusted client (A)'s diet in an attempt to help support their mood and sleep per their power of attorney's guidance. Staff continued to monitor behaviors for both clients and conducted safety checks. As staff witnessed the interaction, 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 3/11/2026 · released to the public 3/18/2026.

SUMMARY OF FINDINGS:On 8/24/25, 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 heard yelling and arrived at Client (A)’s room and found Client (B) in their room. Client (A) alleged Client bit them on their upper arm. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) had teeth marks but no broken skin, the area was treated. Later neither client could recall the incident due to cognitive impairment. Staff implemented frequent safety checks, a door sign was added to deter clients from entering Client (A)’s room. Client (B) will have their medications reviewed for necessary changes. The facility could not determine what happened. 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 12/22/2025 · released to the public 12/29/2025.

SUMMARY OF FINDINGS:On 8/19/25, 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 physical abuse of a client. Staff witnessed Client (A) and (B) in a physical altercation with Client (B) being the aggressor. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Neither client could recall the incident due to cognitive impairment. No visible injuries seen. The clients had increased safety checks implemented, Client (B) was provided with a one-to-one staff for oversight. Additionally, Staff will encourage the clients to eat in different dining 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.

Sent to facility 12/17/2025 · released to the public 12/25/2025.

SUMMARY OF FINDINGS:On 7/19/25, 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 help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (A) alleged they were hit by client (B). During the course of the investigation, the healthcare entity notified law enforcement, conducted interviews, completed an assessment, and reviewed video footage. Video footage revealed client (A) wandered into client (B)’s room and pushed them causing them to fall to the ground. Client (B) sustained a bloody lip requiring basic first aid. The facility increased safety monitoring for client (A) related to wandering behaviors, and updated care plan to reflect redirecting the client when they go to another person’s room, client (B) was offered a plan to keep their door locked more frequently. 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 11/20/2025 · released to the public 11/27/2025.

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. The client was observed on the floor in another client’s room. During the course of the investigation, the healthcare entity reviewed video footage, separated the clients prior to notifying law enforcement, and conducted interviews. Due to cognitive impairment neither client was able to recall the event. Video footage showed client (B) entered client (A)’s room and client (A) attempted to remove client (B) causing them to fall to the ground. The facility started increased safety monitoring, added wandering interventions for client (B), and will frequently check client (A)’s door to ensure it is locked. While physical contact did occur it did not lead to any injury. . 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.

Sent to facility 11/20/2025 · released to the public 11/27/2025.

SUMMARY OF FINDINGS:On 6/21/25, 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. Client (B) was witnessed pushing Client (A) after Client (A) opened their door. Client (A) fell forward and struck their head on a refrigerator. Client (A) was assessed by the paramedics with no further medical interventions necessary at the time. Client (A) did not recall the incident due to cognitive impairment and Client (B) stated they did not like others in their room. Staff will redirect Client (A) when necessary, Client (B) will keep their door locked with a sign posted on their door and staff increased safety checks for 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 11/16/2025 · released to the public 11/23/2025.

SUMMARY OF FINDINGS:On 4/11/25, 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. Client (B) admitted to pushing Client (A). Client (A) was found on the floor and had sustained a laceration to their head. Client (A) was treated in the hospital and received three staples and three stitches. Client (B) had one-to-one oversight implemented while they were awake until they moved out of the facility with family. 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 9/17/2025 · released to the public 9/24/2025.

SUMMARY OF FINDINGS:On 4/3/25, 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 ensured the clients were separated before the police were notified. Client (A) was found on the floor and alleged they were pushed. Client (A) had complaints of pain and were assessed without any further injuries other than a bruise. Client (B) was found to have a bruise above their eye and identified Client (A) as the one who hit them so they hit them back. One-to-one supervision was provided for Client (A). The physical altercation is believed to have occurred. 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 9/16/2025 · released to the public 9/23/2025.

SUMMARY OF FINDINGS:On 4/1/25, 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. During the course of the investigation the healthcare entity ensured Client (A) and the alleged assailant (visitor) were separated before the police were notified. Staff witnessed the visitor holding Client (A) up against a bathroom door against their will while yelling at them. No visible injuries. Client (A) has cognitive impairment and could not recall the incident. The visitor was not allowed back into the facility and staff were informed to call the police if they returned. 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 9/10/2025 · released to the public 9/17/2025.

SUMMARY OF FINDINGS:On 4/1/25, 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. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (B) pick up a book and hit Client (A) in the hip with it. Both clients have cognitive impairment and could not recall the incident. No visible injuries. Staff will be aware of others in Client (B)’s space as they are reactive to others being too close to them. Client (B) was reminded to leave their books in their room and had their medications adjusted. 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 9/10/2025 · released to the public 9/17/2025.

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. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (B) hit Client (A) twice in the back. No visible marks. Both clients have cognitive impairment and could not recall what occurred. Staff were educated to redirect Client (B) when they were showing signs of distress, or frustration. Medication changes were also made to help with negative behaviors. Staff were educated on timely reporting. 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 not submitted within the required timeframe.

Sent to facility 8/28/2025 · released to the public 9/4/2025.

SUMMARY OF FINDINGS:On 2/26/25, 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. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) was found to have bilateral bruising on their wrist and stated a man “grabbed my wrists, tried to choke me and twisted them.” The description described Client (B). One-to-one was provided to Client (B) for the remainder of the day by facility staff and the family was notified the client would need to have one-to-one support while awake. The family moved Client (B) out of the facility due to the inability to pay for one-to-one supervision long-term. The event was substantiated. Client (B) had been in multiple occurrences in the past few months. Please refer to event ID# 2523S293007 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.

Sent to facility 8/14/2025 · released to the public 8/21/2025.

SUMMARY OF FINDINGS:On 3/5/25, 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. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (A) and (B) in physical altercation, observing Client (B) hit Client (A) multiple times. No visible injuries. One-to-one was provided to Client (B) for the remainder of the day by facility staff and the family was notified the client would need to have one-to-one support while awake. The event was substantiated. Client (B) had been in multiple occurrences in the past few months. Please refer to event ID# 2523S293008 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.

Sent to facility 8/14/2025 · released to the public 8/21/2025.

SUMMARY OF FINDINGS:On 2/3/25, 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 (A) grab the throat of client (B). During the course of the investigation, the healthcare entity separated the clients, notified law enforcement, completed an assessment, added one to one supervision, and conducted interviews. Due to cognitive impairments neither client could recall the event. Client (B) had no visible injuries. The facility determined that client (A) experienced increased agitation due to lack of rest and increased pain. The facility implemented increased monitoring of client (A), medication adjustments, and adjustments to the care plan to address rest and pain. The event was substantiated. This is the third report of a client to client altercation involving client (A), please see case ID 2423S293015 and 2423S293018 for more 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.

Sent to facility 8/13/2025 · released to the public 8/20/2025.

SUMMARY OF FINDINGS:On 1/31/25, 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 Client (A) yell and hit Client (B) who was too close to them and Client (B) responded by hitting Client (A) as well. One-to-one supervision was added to Client (A) until they could be seen by their physician and have their medications adjusted as necessary. Staff have been educated regarding Client (A) not liking others in their personal space and when angry or frustrated Client (A) will be removed from the situation. 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 7/30/2025 · released to the public 8/6/2025.

SUMMARY OF FINDINGS:On 1/26/25, 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. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) indicated Client (B) had invited them into their apartment and then was assaulted by Client (B). One-to-one supervision was provided to Client (B) before they were sent to the hospital for aggressiveness. There were no witnesses or injuries. The facility could not determine what occurred as Client (B) is non-verbal and having behaviors during the investigation. Client (B) did not return to the facility and found other living arrangements. 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 7/23/2025 · released to the public 7/30/2025.

SUMMARY OF FINDINGS:On 1/13/25, 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 Client (A) and the alleged assailant (staff #1) were separated before the police were notified. Client (A) alleged about three weeks prior Staff #1 pulled their hair when providing medications and was also verbally abusive. A family member of Client (A) was aware of the allegations and expressed Staff #1 did not have the best manners, however, Client (A) will fixate on someone until they get them fired. Staff #1 indicated Client (A) did not like them and would kick them. Staff #1 was educated on professionalism. No other clients have any concern with Staff #1. Staff were educated to provide care to Client (A) in pairs. There were no witnesses to the allegations made by Client (A). 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 7/16/2025 · released to the public 7/23/2025.

SUMMARY OF FINDINGS:On 12/26/24, 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 help prevent a future recurrence. The healthcare entity reported a physical abuse event. Reportedly, staff (1) cussed at client (B) and handled her in an aggressive and rough manner during care. During the course of the investigation, the healthcare entity suspended staff (1), conducted an assessment and interviews, and started safety monitoring. With client (B)’s dementia, she did not recall the incident and could not participate in a follow-up interview. Per staff (2) witness statement and staff (1)’s work history, the event was substantiated. Staff (1)’s employment was terminated. In addition, staff received re-training on communication expectations with management. 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.

Sent to facility 6/24/2025 · released to the public 7/2/2025.

SUMMARY OF FINDINGS: On 12/9/24, 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 sexual abuse of a client. During the course of the investigation, the healthcare entity, assessed the client and ensured their safety. Staff #1 was removed from duty pending the outcome of the investigation. Client (A) alleged they had been raped by staff #1 when changing her adult incontinent brief. They said a second staff member, staff #2 was also present. Client (A) was transported to the hospital and evaluated and spoke to a forensic nurse; however, she declined a rape kit test. The client did not sustain any known injury. Staff #2 was interviewed and they said they provided the direct incontinence care and staff #1 only helped to turn the client and then s/he left the room. The healthcare entity was unable to confirm sexual abuse occurred based on inconclusive evidence. Staff #1 was no longer employed with the healthcare entity. Client (A)’s care plan was updated. 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 7/5/2025 · released to the public 7/14/2025.

SUMMARY OF FINDINGS:On 11/27/24, 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 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) and (B) in a physical altercation with both having injuries. Both clients were provided first aid. Neither could recall the incident due to cognitive impairment. One-to-one staff was placed with Client (B) during waking hours for safety. Both clients had their medications reviewed for necessary changes. 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 7/9/2025 · released to the public 7/16/2025.

SUMMARY OF FINDINGS:On 11/23/24, 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. The police were notified. It was a misunderstanding by staff member (1) who consumed a client's beverage. Staff member (1) was educated on misappropriation and client property. All staff were provided training again. 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 3/24/2025 · released to the public 3/31/2025.

SUMMARY OF FINDINGS:On 11/18/24, 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 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 client’s care plan was updated to reflect safety interventions to include: safety checks, and to work with the therapy team. 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 2/11/2025 · released to the public 2/18/2025.

SUMMARY OF FINDINGS:On 10/20/24, 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 heard a noise and saw Client (A) and (B) in a physical altercation both sustaining injuries only requiring first aid by staff. One-to-one oversight was implemented for the aggressor Client (B), and medication changes were done. Client (A) will be redirected by staff away from triggering situations and noises. All staff have been made aware of the changes. 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 6/18/2025 · released to the public 6/25/2025.

SUMMARY OF FINDINGS:On 10/15/24, 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. During the course of the investigation the healthcare entity conducted interviews and reviewed documentation. It was alleged that the facility did not provide Client (A) with breakfast or dinner on 10/14/24. Staff #1 who assisted Client (A) stated Client (A) got up late and was provided a snack. When asked about dinner Staff #1 indicted family had given the client a shake so they did not take the client to dinner. Video footage did not align with what Staff #1 stated had occurred and their employment was terminated. Abuse and neglect was reviewed with staff from the ombudsman. 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 8/30/24, 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 (B) hit Client (A) in the back multiple times while Client (A) sat in their wheelchair. Staff indicated Client (B) was overwhelmed in the environment. Both clients have cognitive impairment, however Client (A) did recall being hit. Staff will implement one-to-one time with Client (B) and redirect them to a quiet place when in distress. 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 5/6/2025 · released to the public 5/13/2025.

SUMMARY OF FINDINGS:On 7/7/24, 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. Staff witnessed two clients get into a physical altercation. Client (A) indicated they had pain that subsided after being punched in the head and ear. Client (B) was placed on one-to-one supervision with medications adjustments and hospice support. Staff continued to guide the two clients away from 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.

Sent to facility 4/9/2025 · released to the public 4/16/2025.

SUMMARY OF FINDINGS:On 12/7/24, 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 sexual abuse of a client. During the course of the investigation the healthcare entity ensured the client was safe. The client initially stated someone sexually assaulted them a few nights prior and could not recall who it was to a family member. Then later stated it was only an attempt. The client gave a slight description but did not fit anyone working. The client had confusion during the investigation of what may have happened. The police were notified and determined there was no probable cause. 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 5/17/24, 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 two clients. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. The incident was instigated by client (A) before both clients were involved in the physical altercation that was witnessed by staff. No visible injuries to either client. Both clients have cognitive impairment and the staff will keep them separated with a one-to-one supervision for client (A). Additionally, medication regimens will be reviewed for necessary changes. 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 FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and ombudsman. 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 3/26/2025 · released to the public 4/2/2025.

SUMMARY FINDINGS: On 4/11/24 staff responded to a commotion and found resident (A) covering his face with his arm and resident (B) was nearby alleging resident (A) had hit him first. The residents were separated and assessed. Resident (A) was found to have injuries to his face and provided treatment. Staff notified the police. Resident (A) had cognitive impairment and did not recall the incident, resident (B) stated he should not have reacted in the moment. The facility investigation concluded resident (B) admitted to his actions after resident (A) may have run over his shoes. To help prevent a recurrence, residents were placed on frequent safety checks. Resident (A) had his medications reviewed for changes to help with behaviors while he adjusted to his new environment. Staff will monitor for symptoms of distress from resident (B) and provide support as needed until he adjusts. 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.

SUMMARY FINDINGS: On 3/18/24 family member (1) alleged no staff had checked on resident (A) from 5:49 p.m. until 6:34 a.m. the next day. This was reported after reviewing the camera footage. Qualified medication administration person (QMAP) (1) was assigned to resident (A) and stated they had administered medications to resident (A) at 11:00 p.m. and had a conversation with resident (A). Documentation revealed the medications were administered correctly. Resident (A)’s preference was not to be bothered overnight. The facility investigation concluded the allegation was not substantiated. To help prevent a recurrence, safety checks were identified and added to the care plan according to resident (A)’s request. All staff will assist with the checks and document on a checklist. 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 12/2/2024 · released to the public 12/10/2024.

SUMMARY FINDINGS: On 3/2/24, staff member (1) observed two residents (A) and (B) trying to pull their hands apart and tugged back and forth. Resident (B) slapped resident (A) in his face. Resident (A) then reacted and slapped resident (B) back causing resident (B) to fall. The residents separated when staff member (1) verbally intervened. Resident (B) was assessed and provided pain medication. He was on hospice services. Both residents have cognitive impairment and could not recall the incident. The facility’s investigation concluded abuse was substantiated. Resident (B) was receiving extra support and was placed on 15 minute check ins for safety, behaviors and any necessary medication changes to address any underlying concerns. The family of resident (B) was participating in the care plan changes to lessen the new behaviors for resident (B). This case is linked to incident #2423S293003 because resident (B) was in another event. 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 12/9/2024.

DESCRIPTION OF OCCURRENCE: On 3/1/24, resident (A) had been previously redirected away from resident (B). Resident (A) was seen banging on the door of resident (B)’s apartment by staff. Resident (B) opened her door and yelled loudly before hitting resident (A) in his face. Resident (A) then hit resident (B) back before staff could intervene. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, the ombudsman, Adult Protective Services and the physician. Both residents were separated. No visible injuries seen. Resident (A) had a recent decline and was on hospice. His outburst may be due to pain as he is not able to hold a conversation and was expressive in behavioral concerns. Hospice staff made aware of the immediate concern. Resident (B) stated there have been altercations before but nothing physical, however staff witnessed this incident. Resident (B) did communicate that she was frustrated. The facility investigation was substantiated. Additional staff member stated resident (A) had been previously redirected for behaviors and was counseled on timely reporting. To help prevent a recurrence, staff implemented frequent safety checks with the residents and one-to-one oversight when needed. Resident (B) is being provided extra support for end of life to ensure his quality of life is maintained. 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 2/12/24 staff witnessed resident (B) slap resident (A) on the arm. Resident (A) slapped resident (B) back before being punched on the right side of his forehead. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Staff intervened and separated both residents. Residents had been previously separated as resident (B) tried to take a musical instrument from resident (A) earlier. No visible injuries to either residents. Both residents have cognitive impairment. Staff indicated resident (B) increased in behaviors, maybe a sign of pain. The hospice staff were notified. The facility investigation concluded the incident was witnessed. To help prevent a recurrence, staff will monitor both residents more frequently. Resident (B) had medication changes and will be monitored for effectiveness. 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 12/7/23, a resident (A), in his 80s, was found on the floor lying on his back without any clothes on, at 6:40 a.m. Resident had an incontinence episode, Staff member (1) who found resident (A) also noticed blood smears next to the shower in the resident’s bathroom and a large contusion to the right side of resident (A)’s forehead. Resident (A) was not moved prior to being transferred to the hospital. Emergency services were called and resident (A) was taken to the hospital and diagnosed with a brain bleed and hip fracture. Resident (A) could not recall what happened when asked prior to going to the hospital. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Resident (A) required surgical intervention. The facility investigation concluded resident (A) had an unwitnessed fall injuring his head and his hip. He most likely tried to transfer himself to his wheelchair to use the bathroom and fell. Resident (A) required rehabilitation services prior to returning to the facility. To help prevent a recurrence, resident (A)’s plan of care will be adjusted to meet his ambulation needs when he returns to 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.

Sent to facility 11/8/2024 · released to the public 11/15/2024.

DESCRIPTION OF OCCURRENCE: On 11/11/23 a female resident (A) in her 90s was seated in her wheelchair by a public telephone. Resident (A) screamed out and the concierge and care manager went to the area. Resident (A) stated a male resident (B) in his 80s hit her on the head twice. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. The residents were separated. Resident (B) stated he hit resident (A) because she did not hang up the phone correctly. Resident (B) can become overwhelmed in the evening and noisy environments. Both residents have cognitive impairment, however, resident (B) knows he hit resident (A). Resident (A) did not recall the event afterwards. The facility investigation concluded resident (B) admitted to hitting resident (A) on the head. To help prevent a recurrence, resident (B) has a companion stay with him for the safety of other residents everyday from 4:00 p.m. until he goes to bed. Resident (B) will be encouraged to do things he likes in his room in the evenings where it is less noisy and not overly stimulating for him. Staff will monitor resident (B) when he does not have his companion with him. 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 11/5/2024 · released to the public 11/12/2024.

DESCRIPTION OF OCCURRENCE: On 10/6/23, staff witnessed resident (B), in her 70s, reach out and strike resident (A)'s arm. Resident (A) was in her 90s. Resident (B) then attempted to push resident (A) in her wheelchair before anyone could intervene. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Both residents were separated. Resident (A) stated immediately after the altercation, “what is wrong with that lady.” Resident (A) did not have any visible injuries. Resident (B) was unable to verbally communicate and was being monitored by a private companion currently because of behaviors when she becomes frustrated. Per staff, the companion was not close enough to resident (B) to intervene quickly. The facility investigation concluded the incident did occur as described and the incident was unprovoked. Staff reported resident (B) possibly became physical with resident (A) after becoming frustrated. To help prevent a recurrence, the private companion of resident (B) has been asked to stay closer to her and redirect when needed. In addition, facility staff implemented line of sight monitoring with resident (B) for more supervision. 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 9/26/2024 · released to the public 9/26/2024.

DESCRIPTION OF OCCURRENCE: On 6/23/23, six cans of dog food was reported missing. The cans had been purchased with resident (A)'s money. Staff reported 12 cans had been present the night before in a sealed box. Staff found the box open with six cans missing. The box was present in the resident's apartment. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, ombudsman and Adult Protective Services. When reviewing the information, staff reported no cans should have been used between the evening of 6/22 and 6/23 (morning). Staff helped feed the resident's dog. All remaining cans were secured. Twelve staff members were interviewed and no one indicated witnessing anyone remove dog food from her apartment. The facility was unable to determine what happened or identify an alleged assailant. To help prevent a recurrence, the surplus dog food was placed in the nursing office and the other cans were secured. 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 4/8/2024 · released to the public 4/12/2024.

DESCRIPTION OF OCCURRENCE: On 5/10/23, staff reported resident (B) was trying to pass resident (A) in the hallway but could not get around. Resident (B), in her 80s, became angry and proceeded to hit resident (A)'s wheelchair and pulled her hair. Resident (A), in her 80s, had a diagnosis of dementia and was not able to participate in a follow up interview. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, ombudsman, Adult Protective Services and physician. Staff separated the residents and provided additional oversight. Resident (A) was assessed and no visible injuries were observed. Staff reported resident (B) had a severe cognitive impairment with a history of physical aggression. Later, neither resident could recall the altercation. From the findings, the facility substantiated the allegation of resident (B) physically reacting when she became angry and frustrated by the situation. Staff continued monitoring the residents to intervene and redirect if resident (B) was having a negative interaction with any other residents. A few weeks later, resident (B) was discharged from 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.

Sent to facility 2/20/2024 · released to the public 2/20/2024.

DESCRIPTION OF OCCURRENCE: On 5/9/23, when morning shift arrived, they observed resident (A), in her 80s, sitting in a chair in the dining room. Allegedly, she had been sitting in the chair all night as staff (1) did not assist her to bed the night before. The resident (A) had a severe cognitive impairment and required assistance with her ADL needs. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, ombudsman, Adult Protective Services and physician. Day shift staff assisted the resident (A) with care and helped her to bed. Staff reported she was heavily soiled due to incontinence. Management suspended staff member (1) pending investigation. Staff (1) said they attempted several times to care for the resident, but the resident refused, which was her right. Another staff member (3) said staff (1) made several attempts to care for the resident (A) that shift. Other staff said they asked staff (1) if assistance was needed, but the requests were declined. The facility investigation concluded at no time did staff member (1) reach out to other staff for assistance to help care for resident (A). Per the facility, everyone should work as a team to help ensure resident care needs are met. When reviewing staff member (1)'s personnel record, the facility noted other complaints had been filed regarding their lack of attention to resident care. Staff member (1)’s employment was terminated. Education was provided to staff regarding their approach techniques, abuse and neglect reporting and asking other staff members for assistance. 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 2/20/2024 · released to the public 2/20/2024.

DESCRIPTION OF OCCURRENCE: On 4/30/23, two staff members discovered resident (A), in her 70s, in resident (B)'s room. They were observed lying naked in resident (B)'s bed and potentially engaged in sexual relations. She told staff she wanted to go to bed and then resident (B) used his body to block resident (A)'s body. Staff intervened and assisted resident (A) back to her room. Resident (B) was in his 80s with a history of sexually inappropriate behaviors. She had a severe cognitive impairment and he was alert and oriented. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians, and ombudsman. Fifteen-minute safety checks were started with resident (B). Resident (A) was assessed by her physician and the family reported the assessment was inconclusive regarding sexual contact. Resident (A) was placed on medication prophylactically for sexually transmitted diseases. With her cognitive impairment, she was unable to participate in a follow up interview. Staff reported she was not exhibiting signs of distress or fear following the event. Resident (B) stated two consenting 50 year old adults ought to be able to make their own decisions and staff were inappropriate to intervene. One staff member reported this was the second incident of finding resident (B) with another female in his room, but that resident was fully clothed and he was naked. That resident no longer resided in the facility. From the investigation, the facility was unable to determine if sexual penetration occurred. However, resident (A) did not have the cognitive ability to provide informed consent. The community recognized staff could not guarantee the safety of severely cognitively-impaired residents or maintain the 15-minute checks long-term. The facility issued a five-day emergency move out notice to resident (B). His physician adjusted his medications to help manage sexual impulses. Fifteen-minute safety checks remained in place until his discharge to another location. In addition, staff was educated to report sexual contact between residents so management could assess the situation. 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 2/5/2024 · released to the public 2/5/2024.

DESCRIPTION OF OCCURRENCE: On 4/27/23, a resident (A), in her 80s, reported another resident (B), in her 80s, tried to enter her apartment and she attempted to redirect her back out. As this interaction occurred, resident (B) allegedly rammed her walker into resident (A)’s left shin causing a skin tear. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, ombudsman, Adult Protective Services and physician. The incident was not witnessed and the residents were separated by the time it was reported. Staff confirmed the presence of a skin tear to resident (A)'s shin and provided first aid treatment. Resident (A) stated she felt safe and did not want to file a complaint. Resident (B) did not recall the event and talked about other things during the interview due to her cognitive impairment. The facility investigation concluded resident (B)'s actions caused a skin tear to resident (A)'s left shin. To help prevent a recurrence, environmental changes occurred to help resident (B) identify the location of her apartment. 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 1/15/2024 · released to the public 1/16/2024.

DESCRIPTION OF OCCURRENCE: On 4/23/23 as witnessed by case manager (1), a female resident (A) in her 80s was standing with two other residents when a male resident also in his 80s walked up to her and slapped resident (A) in the face. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, ombudsman, Adult Protective Services and physician. Residents were immediately separated. No visible injuries were discovered to resident (A) immediately after, however, resident (A) has cognitive impairment due to advanced Alzheimer’s Disease and did display an angry face after the physical altercation. Resident (B) stated that he was angry but did not recall slapping resident (A)in the face. Case manager (1) confirmed what they witnessed and indicated resident (B) maybe in pain according to documentation. The facility investigation concluded the incident was witnessed, resident (B) slapped resident (A) in the face unprovoked. To help prevent a recurrence staff will redirect resident (B) and monitor his location. Staff will also be observant of resident (B)’s pain and treat with pain medication to help with 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 11/19/2023 · released to the public 11/20/2023.

DESCRIPTION OF OCCURRENCE: On 3/29/23, there was a report of resident (A) following resident (B) into her apartment. Resident (B) tried to shut her door to keep resident (A) out. As this occurred, resident (A) swung at resident (B) causing a scratch on resident (B)'s neck and one forearm. Both residents were in their 80s and were cognitively impaired. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians, ombudsman and Adult Protective Services. Staff separated the residents. Resident (B) was assessed and had superficial scratches on her neck and right forearm. The scratches were cleaned and treated. Resident (A) was not able to remember the incident. Staff were educated to redirect resident (A) when she is wandering into other residents' apartments. Environmental changes occurred to help resident (A) identify her own apartment. 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 11/3/2023 · released to the public 11/3/2023.

DESCRIPTION OF OCCURRENCE: On 2/27/23 staff member (1) was assisting a male resident (A) in his 80s with his walker, however, staff member (1) positioned resident (A) to sit on his walker and proceeded to push him backwards over a threshold and the walker tipped backwards. Resident fell and hit his head and his back on the floor. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the physician, and families/guardians. Resident (A) was sent to the emergency room for an evaluation and treatment if necessary. The CT-scan was normal. Resident (A) was treated at the facility for pain and soreness. No other staff member saw the incident. The facility investigation concluded staff member (1) (agency staff) did not follow the manufacturer guidelines for the walker. Staff member (1) was sent home and the incident was reported to her company. To help prevent a recurrence staff were provided training on safety with ambulation and the correct use of equipment. Staff member (1) was banned from picking up any other shifts. 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 10/3/2023 · released to the public 10/3/2023.

DESCRIPTION OF OCCURRENCE: On 2/26/23 a female resident (A) in her 80s was seated in the dining room and may have been close to a male resident (B) in his 80s table. Resident (B) grabbed resident (A) face in the chin area causing a scratch to the area. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians, Adult Protective Services and ombudsman. Residents were separated. The scratch to resident (A)s face was cleaned. Resident (A) has cognitive impairment and limited speech, unable to provide a statement. Resident (B) has a diagnosis of traumatic brain injury and demonstrated using his own body that he grabbed resident (A). The facility investigation concluded the resident (B) was triggered by resident (A) in his space and grabbed resident (A) causing a scratch to her face. To help prevent a recurrence the care plan for resident (B) was updated to ensure personal space and direct other residents away from him when he is working on projects or in the dining room. Staff will continue to redirect other residents and resident (A) in the dining 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 8/14/2023 · released to the public 8/14/2023.

DESCRIPTION OF OCCURRENCE: On 2/16/23 two male residents (A) and (B) both in their 70s were in a verbal altercation which turned into a physical altercation after staff intervention. When being redirected resident (B) started swinging at resident (A) who then dropped his coffee mug and spilled coffee on himself. Resident (A) had a skin abrasion to his ring finger from the broken coffee mug which was treated by staff. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians, Adult Protective Services and ombudsman. During the investigation after both residents were redirected and staff were directing another resident out of the area, management saw resident (B) again attempt to swing at resident (A) in the hallway. Resident (A) then threw his coffee on resident (B). Resident (B) was assessed without any visible injuries from the coffee. After this resident (B) attempted to go after resident (A) for the third time calling him names and trying to punch resident (A). Resident (A) diverted the attempts and staff intervened. Resident (A) stated he was attacked by resident (B) with his fists and was kicked in the upper left leg. Resident (B) stated, “he beat the snot out of superman because he was being ugly while I was trying to program the television”. Staff reported that what started as a verbal altercation turned into a physical altercation. Resident (B) was sent out to a local hospital for evaluation and treatment as necessary. Resident (B) was transferred to a higher level of care to better assist with his diagnoses. The facility investigation concluded resident (B) actions against resident (A) were reckless and caused injury. To help prevent a recurrence resident (B) no longer resides at the facility. No changes were made to resident (A)’s plan of 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 agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 9/6/2023 · released to the public 9/10/2023.

DESCRIPTION OF OCCURRENCE: On 2/14/23 qualified medication administration person (QMAP) (1) through an agency, stated they could not find the Lorazepam .5mg (milligram) for a female resident (A) in her 90s in the medication cart that they had signed out. QMAP (1) stated they then took the same medication and dose from another resident and administered it to resident (A). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the physician, and families/guardians. After this self admission QMAP (1) was removed from the schedule and suspended from shifts through the agency. No changes to resident (A) or the other resident. QMAP (1) deviated from the policy intentionally and should have marked the medication as unavailable rather than use another resident's medication. The facility investigation concluded that QMAP (1) intentionally diverted another resident's medication and gave it to resident (A). However, it was the same medication and dose. To help prevent a recurrence QMAP (1) was suspended from picking up shifts and all other QMAPs were provided training again on the process for when a medication was unavailable. The medication carts will be audited for timely refill of medications. 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 9/6/2023 · released to the public 9/6/2023.

DESCRIPTION OF OCCURRENCE: On 2/7/23 staff member (1) heard yelling and a verbal altercation between a female resident (A) in her 70s and a male resident (B) in his 80s. When staff member (1) arrived in the area, resident (A) was yelling out and held her right brow area with her hand which was red and resident (B) was shouting at resident (A) to get out. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, and families/guardians. Resident (B) was redirected to the east side of the facility where his bedroom was located. Resident (B) was assessed, the red area seen may be a patch of red skin that she has, however was holding this area when staff arrived. First aid, an ice pack was applied to the area. No staff had witnessed the incident. The facility investigation concluded that resident (A) and (B) approached each other in the hallway and engaged in an altercation, unwitnessed. To help prevent a recurrence both residents will be monitored for safety and staff were instructed to monitor change in demeanor or condition. The physicians were notified for residents. Medications were adjusted for resident (B), a urinalysis was done to see if this was a cause for increased behaviors. Resident (B) was eventually moved to a higher level of 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 agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 8/14/2023 · released to the public 8/14/2023.

DESCRIPTION OF OCCURRENCE: On 1/9/23 a male resident (A) who is non communicative was walking the hall at night as he normally did when another male resident (B) was outside his door walking the other way. Resident (B) said something to resident (A), and when resident (A) did not respond as he is (non communicative) resident (B) swung at resident (A) and made contact with his mouth which caused resident (B) to lose his balance and fall to the floor. The incident was witnessed by staff member (1). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, and families/guardians. Staff separated the two residents. Resident (A) sustained a split lip that was treated. No visible injuries to resident (B). Both residents have cognitive impairment. Resident (A) could not state who hit him. Resident (B)’s answers were unclear. Staff member (1) stated the incident happened so fast and was unprovoked. The facility investigation concluded the incident was witnessed by staff member (1), resident (A) was hit by resident (B) and sustained a split lip. To help prevent a recurrence staff were to redirect residents away from each other. A request for medication review was made for resident (B) to help with his paranoia, bipolar and dementia diagnosis. Additional safety checks were provided by staff. 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.