14
Inspections
15
Deficiencies
0
Actual Harm or Above
17
Occurrences
May 26, 2026
Last Inspection
S/S A/B Minimal potential
The most recent inspection of MORNINGSTAR OF ARVADA on record is dated May 26, 2026. Across 14 published inspections, state surveyors cited 15 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
Missing Admin Information
Owner
EASLEY SENIOR CARE LLC
Phone
(720) 907-9071
Payor Source
Private Pay
City
ARVADA
ZIP
80007
Inspections & Citations
14 inspections · 15 deficiencies5/26/2026Licensure Complaint · ID M5T2115 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO42259, was completed on 5/27/26. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0410Rpt Req-At Risk/Mndtry RprtS/S B▼
Findings
Based on record review and interviews, the residence failed to report suspected physical abuse and neglect to law enforcement within 24 hours of observation or discovery, affecting one of three sample residents (#1) and one former resident (#5). (Cross-reference U0540 and U1410)Findings include:1. Resident #1 was admitted to the residence on 6/8/24 with diagnoses including traumatic subarachnoid hemorrhage, and Parkinson's disease. Progress notes for Resident #1 for March and May 2026 revealed as follows: On 3/10/26, Former Resident #4 (Resident #1's wife) threw a newspaper at Resident #1 and pushed Resident #1 repeatedly. On 3/16/26, Former Resident #4 pushed Resident #1. Staff asked Former Resident #4 to stop; however, Former Resident #4 continued to push Resident #1. On 3/24/26, Former Resident #4 punched Resident #1 repeatedly and pulled Resident #1 up by his neck as Resident #1 asked Resident #4 to stop. On 5/7/26, Former Resident #4 "swatted" Resident #1 in the dining room. 2. InterviewsOn 5/27/26 at 10:30 a.m., the reflections coordinator (RC) stated she is responsible for reading residents ' progress notes. RC stated she was aware of incidents on 3/10, 3/16, 3/24, and 5/7/26. The RC stated she reported to the administrator, but she considered these incidents to be a "husband and wife concern" and did not require further interventions, nor was she aware she had to contact law enforcement. On 5/27/26 at 10:43 a.m., the administrator stated that he was unsure whether he was aware of the incidents on 3/10, and 3/16/2026. The administrator stated was aware of the incident on 3/24/26, and he believed that Former Resident #4 "was losing patience" with Resident #1. The administrator stated no further interventions were taken, investigations were not conducted, nor were the incidents reported to law enforcement. 2. Similar deficient practice was found for Former Resident #5 for neglect.
Plan of correction · submitted by the facility
Immediate Corrective Action:The Executive Director reviewed the incidents involving Resident #1 and Former Resident #5. Immediate interventions and Short-Term Observations (STOs) were implemented upon identification of any allegation, observation, or suspicion of abuse, neglect, exploitation, or mistreatment. The alleged aggressor was removed from the community during the investigation. The resident was evaluated for fear of the spouse by law enforcement, and supervised visitation was implemented. All required reporting was completed once the deficiency was identified. Systemic Changes:Daily Clinical Stand-Up meetings now include review of all ALIS observation notes, progress notes, incident reports, and resident concerns from the prior 24 hours. Any incident, allegation, observation, or concern that may meet state reporting requirements is escalated the same business day to the RVPO and RVPW.Resident-specific interventions, protective measures, and STOs are initiated immediately upon identification of a potentially reportable event. All staff and department leaders receive education on mandatory reporting requirements, identification of abuse/neglect, reporting timeframes, and documentation expectations. Monitoring Frequency: Daily review of all ALIS documentation, progress notes, incident reports, and family concerns during Clinical Stand-Up. Documentation Method: Monitoring will be documented on the Daily Clinical Review Log, including:Date reviewedDocuments reviewedIdentified concernsReporting actions takenLeadership sign-offLogs will be retained in the POC Monitoring Binder. Representative Sample: A rotating 10% sample of residents, representing both Assisted Living and Memory Care, will be reviewed weekly. Minimum Monitoring Duration: Monitoring will continue for a minimum of 3 months. Strategic Plan Integration: Daily Clinical Stand-Up and leadership oversight processes outlined in the Strategic Sales, Marketing & Operations Plan support ongoing monitoring and compliance. All state-reportable events will be reviewed through the community's Quality Assurance and Performance Improvement (QAPI) process to ensure timely reporting, appropriate interventions, completion of investigations, and implementation of corrective actions.
0540Admin-Dts RespS/S B▼
Findings
Based on record review and interviews, the residence failed to ensure the administrator managed day-to- day delivery of services to ensure that the residents receive the care that is described in the resident agreement, the comprehensive resident assessment, and the resident care plan, and failed comply with state laws and submitting all reports and records required by the department, affecting 87 current residents. (Cross-reference U0410, U1150 and U1410). 1. Mandatory ReportingResident #1 was admitted to the residence on 6/8/24 with diagnoses including Traumatic Subarachnoid Hemorrhage, and Parkinson's Disease. Former Resident #4 assaulted her husband three times in March 2026 and once in May 2026. The administrator failed to notify law enforcement within 24 hours. The administrator failed to contact Adult Protective Services (APS) following these incidents. On 5/27/26 at approximately 12:30 p.m., the administrator said he was not aware of the three March 2026 assaults and the assault on 5/7/26, so law enforcement was not notified, as required. 2. Care PlanFormer Resident #5 was admitted to the residence on 7/20/24 with diagnoses including vascular dementia, atrial fibrillation, sleep apnea, hypertension, and glaucoma. Review of Former Resident #5 ' s care plan indicated that the resident required three nightly checks. A record review of video surveillance from Former Resident #5 ' s family member showed the resident awake and alone in her room from hours of 10:00 p.m. on 4/10/26 until 6:00 a.m. on 4/11/26. A shift hand off note and progress note indicated that Former Resident #5 was found on 4/11/26 at 6:00 a.m. "wet and naked."On 5/26/26 at 2:00 p.m. Former Resident #5 ' s family member stated she spoke with the wellness director (WD) on 4/11/26 but had not received a follow-up correspondence until 4/18/26. On 5/26/26 at 3:30 p.m., the wellness director (WD) stated that she spoke with family member of Former Resident #5 on 4/11/26 concerning the incident on 4/10 - 4/11/26. Following the phone call, she texted the care team. There was no follow-up from the administrator until 4/18/26. On 4/18/26 there was a care conference with the family. The WD acknowledged that she reported the allegation to the administrator; however, no further actions were taken. An electronic communication dated 4/21/26 addressed to the administrator, wellness director (WD), and reflections coordinator (RC) from Former Resident #5 ' s family member read, resident was not checked on for approximately 12 hours on 4/10 - 4/11/26. An electronic communication dated 4/27/26 from the administrator read that their investigation was continuing. An electronic communication dated 5/2/26 from the family member of Former Resident #5 read "Is there an update for us on where your investigation sits? Or next steps?"An electronic communication dated 5/4/26 from the administrator read that there was confirmation "that the team members were not following Former Resident #5 ' s care plan."3. Investigations of Abuse and Neglect AllegationsOn 5/26/26 at 4:00 p.m., the administrator stated he received an electronic communication from the family member of former Resident #5 on 4/21/26 concerning an incident that former Resident #5 was left in bed 12 hours spanning 4/10 - 4/11/26. He added that he may have been notified of these incidents prior to 4/21/26, but that these appeared to be "care issues," and the WD talked to staff, and it did not require any further intervention. On 5/26/26 at approximately 8:00 a.m., a request for all investigations from the last 90 days was made. A record review revealed that an internal investigation had not been conducted for incidents between Former Resident #4 and Resident #1 on 3/10, 3/16, 3/24, 5/7, and 5/20/26. Changes to the care plan were not documented following those incidents. Interventions were not put in place to prevent further incidents from occurring. On 5/27/26 at 10:43 a.m., the administrator stated that the incident on 3/24/26 between Former Resident #4 and Resident #1 was brought to his attention. Interviews with the Resident #1 and Former Resident #4, or staff were not conducted. Changes to Resident #1 ' s care plan was not done. The administrator stated he was not sure he was aware of the incidents on 3/10/26, 3/16/26, and 5/7/26. On 5/27/26 at 12:30 p.m. The administrator, who was responsible for the day-to-day, stated that staff required further training on mandatory reporting guidelines. Proper investigations needed to be done for any allegations of abuse and/or neglect including interviewing staff and residents involved.
Plan of correction · submitted by the facility
Immediate Corrective Action:The Executive Director reviewed all incidents and ensured appropriate reporting and protective interventions were implemented. The alleged aggressor was removed from the community during the investigation. Resident #1 was evaluated for fear of the spouse and supervised visitation was implemented. All required reporting notifications were completed upon identification of the deficiency. Systemic Changes:Daily Clinical Stand-Up includes review of all documentation to identify potential reportable events. All allegations or concerns are escalated the same business day to the RVPO and RVPW.Education:The Executive Director and Wellness Director will provide education to all staff on mandatory reporting requirements, abuse and neglect identification, investigation expectations, care plan compliance, and documentation standards. Monitoring Frequency: Weekly audits by the Executive Director of progress notes, incident reports, and care delivery documentation. Documentation Method: Use of the Administrator Oversight Audit Tool, documenting:Items reviewedCompliance statusCorrective actionsStaff follow-upReporting verificationRepresentative Sample: A 10% representative sample of residents across all shifts and care levels. Minimum Monitoring Duration: At least 3 months. All state-reportable events will be reviewed through the community's Quality Assurance and Performance Improvement (QAPI) process to ensure timely reporting, appropriate interventions, completion of investigations, and implementation of corrective actions.
1150Res Care Srvs-Res CPS/S A▼
Findings
Based on record review and interviews, the residence failed to ensure each resident's care plans were detailed with specific personal service needs and preferences, along with the staff tasks necessary to meet those needs, affecting one former resident (#5). (Cross-reference U0540)Findings include:1. Former Resident #5 admitted to residence on 7/20/24 with a diagnosis of vascular dementia, atrial fibrillation, sleep apnea, hypertension and glaucoma. A care plan, dated 12/29/25, read that Former Resident #5 required three wellness checks a night. A document in Former Resident #5's record, titled "hand off notes" dated 4/11/26 at 6:04 a.m., written by Staff #1, read that Former Resident #5 was found awake, naked, and bedding soaked at morning rounds. A document in Staff #1's personnel file revealed a disciplinary document, dated 4/28/26 and read that Staff #1 received a final written notice for not providing care and services to Former Resident #5 for approximately 12 hours during the overnight shift on 4/10 to 4/11/26. A record review of Former Resident #5's care plan read the resident required cues to eat meals. An electronic communication dated 5/11/26 from Former Resident #5 ' s family member read upon arrival at the residence, Former Resident #5 ' s silverware was wrapped, and it appeared that Former Resident #5 ' s soup had gone uneaten, and the staff had begun to clear dinner plates. An electronic communication dated 5/13/26 from the administrator read they were going to discuss the residents' needs with staff again, and there was concern that staff were "trying to cover themselves from getting in trouble," making it difficult to figure out what had happened and rectify the situation. 2. InterviewsOn 5/26/26 at 9:30 a.m., the family of Former Resident #5 stated cameras placed in Former Resident #5's room showed the resident sitting on the edge of the bed from 10:00 p.m. on 4/10/26 until 4/11/26 at 6:00 am. Staff did not enter the room during this time span. On 5/26/26 at 2:00 p.m., Staff #3 stated Former Resident #5 was not checked during an overnight shift on 4/10/26 until morning rounds at 6:00 a.m. on 4/11/26. On 5/26/26 at 2:40 p.m., the family member of Former Resident #5 stated she spoke with the wellness director (WD) on 4/11/26 at 1:16 p.m. and informed her that Former Resident #5 was not checked on overnight. On 5/26/26 at 3:36 p.m., the wellness director (WD) acknowledged that staff had not checked on Former Resident #5 during the overnight shift on 4/10/26. On 5/27/26 at approximately 12:30 p.m., the administrator said staff did not follow Former Resident #5's care plan and as a result, Former Resident #5 was not checked on during the overnight shift on 4/10/26 to 4/11/26. He added that the care plan was not followed on 5/11/26 when staff did not cue Former Resident #5 during meals until her family member arrived.
Plan of correction · submitted by the facility
Immediate Corrective Action:Care plans and documentation for Former Resident #5 were reviewed. Staff were counseled regarding failure to follow care plan requirements. Systemic Changes:All Memory Care resident care plans will be reviewed and updated to include specific, measurable staff tasks. Updated care plans will be reviewed with direct care staff on their next shift. Daily Clinical Stand-Up includes review of ALIS observations, incident reports, and family concerns. Any failure to follow a care plan is escalated the same business day. Education:The Executive Director and Wellness Director will provide education to all staff regarding care plan compliance, including expectations for overnight checks, meal cueing, documentation in real time, and escalation of missed care. Monitoring Frequency: Weekly care plan compliance audits by the Wellness Director. Documentation Method: Use of the Care Plan Compliance Audit Tool, documenting:Resident sampledTasks reviewedCompliance statusCorrective actionsStaff retrainingRepresentative Sample: A rotating 10% sample of Memory Care residents. Minimum Monitoring Duration: At least 3 months. Strategic Plan Integration: Daily Clinical Stand-Up and documentation review processes support ongoing monitoring. Audit results will be reviewed through the Quality Assurance and Performance Improvement (QAPI) process and submitted to regional leadership weekly.
1322Res Rghts Rts/Rspn-Civ/Rel-Abuse/Neg/MisaproS/S B▼
Findings
Based on record review and interview, the residence failed to observe the resident's right to civil liberties including the right to be free from physical abuse, affecting one of three sample residents (#1). (U0410, U0540, U1410) Findings Include: 1. Resident #1 was admitted to the residence on 6/8/24 with diagnoses including Traumatic Subarachnoid Hemorrhage and Parkinson ' s Disease. Progress notes for Resident #1 for March and May 2026 revealed: On 3/10/26, Former Resident #4 (Resident #1's wife) threw a newspaper at Resident #1 and pushed Resident #1 repeatedly. On 3/16/26, Former Resident #4 pushed Resident #1, staff asked Former Resident #4 to stop, Former Resident #4 continued to push Resident #1. On 3/24/26, Former Resident #4 punched Resident #1 repeatedly and "pulled Resident #1 up by his neck" as Resident #1 asked Former Resident #4 to stop. On 5/7/26, Former Resident #4 "swatted" Resident #1 in the dining room. On 5/20/26, Resident #1 refused to swallow his medications, and Former Resident #4 got upset and placed the medications into his mouth and spat on him. Local law enforcement was called to the residence. The local law enforcement obtained statements from all parties involved. The residence contacted the Resident #1 and Former Resident #4's Power of Attorney (POA). There were no internal investigations provided by the residence for the progress notes on 3/10, 3/16, 3/24, 5/7, and 5/20/26 when Former Resident #4 physically assaulted Resident #1. The residence's care plan for Resident #1, dated 4/14/26, read that staff were to support the resident and provide emotional support to address needs, and provide safety checks at least twice a shift and address needs. 2. InterviewsOn 5/26/26 at approximately 3:36 p.m., the WD stated she was aware of incidents between Resident #1 and Former Resident #4. She stated that an interview had been conducted with Resident #1 on 5/20/26 with the reflections coordinator (RC) and WD, that revealed Resident #1 was fearful of Former Resident #4 ' s feelings. On 5/27/26 at 10:30 a.m. The reflections coordinator (RC) stated she is responsible for reading residents ' progress notes. The RC stated she was aware of incidents on 3/10, 3/16, 3/24, and 5/7/26. The RC stated she reported to the administrator, but she considered these incidents to be a "husband and wife concern" and did not require further interventions. The RC stated she contacted law enforcement on 5/20/26 following an incident with Former Resident #4 and Resident #1 at the direction of the administrator. The individuals were then separated and interviewed by law enforcement. Staff #3 was interviewed by the RC concerning the incident on 5/20/26. On 5/27/26 at 10:43 a.m. The administrator stated that he was unsure whether he was aware of the incidents on 3/10, and 3/16/26. The administrator stated was aware of the incident on 3/24/26 and he believed that Former Resident #4 "was losing patience" with Resident #1. He acknowledged that no further interventions were taken, investigations were not conducted, nor were the incidents reported to law enforcement. The administrator stated Resident #1 was emotionally fearful of Former Resident #4. On 5/27/26 at approximately 12:30 p.m., the administrator said he expected residents to be free from abuse and for staff to report either suspected abuse or confirmed abuse to him right away.
Plan of correction · submitted by the facility
Citation #4Immediate Corrective Action:Resident #1 and Former Resident #4 incidents were reviewed by the Executive Director and Wellness Director. The resident was evaluated for safety, emotional distress, and fear related to the spouse. Appropriate protective interventions were implemented, including separation of parties and coordination with law enforcement during the most recent incident. All staff involved were re-educated regarding mandatory reporting expectations, including the requirement that all suspected abuse, must be treated as potential abuse and immediately escalated for investigation and reporting. Law enforcement was contacted and involved for the 5/20/26 incident, and appropriate notifications were completed per regulatory requirements. Identification of Residents Potentially Affected:The Executive Director and Wellness Director completed a review of all Observation notes and incident reports for all residents over the past 90 days to identify any additional unreported or under-investigated allegations of abuse, neglect, or mistreatment. Systemic Changes:All allegations or suspicions of abuse are escalated the same business day. Daily Clinical Stand-Up includes review of documentation to identify potential rights violations. Any suspected or confirmed abuse event will be escalated the same business day to the Executive Director, Regional Vice President of Operations (RVPO), and Regional Vice President of Wellness (RVPW) for review, investigation direction, and reporting decisions and reported to all appropriate authorities. A standardized investigation process is implemented for all allegations. Monitoring Frequency: Daily review of progress notes, behavioral notes, and incident reports during Clinical Stand-Up. Documentation Method: Use of the Resident Rights Compliance Log, documenting:Identified concernsProtective interventionsReporting actionsFollow-upMinimum Monitoring Duration: At least 3 months. All findings will be reviewed through the Quality Assurance and Performance Improvement (QAPI) process monthly. Community to hold Monthly Family council meetings for first 3 months, followed by quarterly family council meetings scheduled in advance with adequate notice to all family members for feedback and communityperformance review
1410Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S B▼
Findings
Based on record review and interview, the residence failed to report allegations of abuse and neglect to the appropriate agencies, failed to notify legal representative about the allegation within 24 hours, failed to notify adult protective services (APS), failed to conduct a thorough investigation including outlining the investigative process and ongoing monitoring, failed to provide documented findings to the department upon request, failed to provide appropriate corrective action, and failed to retain a copy of the report with the investigation findings affecting one of three sample residents (#1) and one former resident (#5). (Cross-reference U0410, U0540 and U1322)Findings Include:1. Resident #1 was admitted to the residence on 6/8/24 with diagnoses including Traumatic Subarachnoid Hemorrhage and Parkinson's Disease. Progress notes for Resident #1 for March and May 2026 revealed: On 3/10/26, Former Resident #4 (Resident #1's wife) threw a newspaper at Resident #1 and pushed Resident #1 repeatedly. On 3/16/26, Former Resident #4 pushed Resident #1, staff asked Former Resident #4 to stop, Former Resident #4 continued to push Resident #1. On 3/24/26, Former Resident #4 punched Resident #1 repeatedly and "pulled Resident #1 up by his neck" as Resident #1 asked Former Resident #4 to stop. On 5/7/26, Former Resident #4 "swatted" Resident #1 in the dining room. On 5/20/26, law enforcement were notified of an incident between Former Resident #4 and Resident #5. Former Resident #4 put pills in Resident #1 ' s mouth after he refused, then spit on him. There were no internal investigations provided by the residence for the progress notes on 3/10, 3/16, 3/24 and 5/7/26 when Former Resident #4 assaulted Resident #1. There was no record that adult protective services (APS) was contacted. 2. InterviewsOn 5/27/26 at 10:30 a.m., the reflections coordinator (RC) stated she was responsible for reading residents ' progress notes. The RC stated she was aware of incidents on 3/10, 3/16, 3/24 and 5/7/26. The RC stated she reported instances to the administrator and wellness director, but they considered this "a husband and wife concern" and did not require further interventions. She was unaware that she had to report the incidents to law enforcement. She acknowledged that no other internal investigations were conducted. On 5/27/26 at 10:43 a.m., the administrator stated that he was unsure whether he was aware of the incidents on 3/10, 3/16, and 5/7/26. The administrator stated was aware of the incident on 3/24/26, and he believed that Former Resident #4 was losing patience with Resident #1. No further interventions were taken, investigations were not conducted, nor were the incidents reported to law enforcement. The RC interviewed Staff #3 as she witnessed the incident, but did not provide documentation of the interview with Staff #3. The administrator was unable to provide documentation of an internal investigation for incidents on 3/10, 3/16, 3/24, 5/7, or 5/20/26. The administrator stated that local law enforcement conducted an investigation on 5/20/26, and acknowledged APS was not contacted for any of the above incidents. 2. Similar deficient practice was found for Former Resident #5 for allegations of neglect.
Plan of correction · submitted by the facility
Immediate Corrective Action:Incidents were reviewed, protective interventions implemented, and required notifications completed. A 90-day review of ALIS notes, progress notes, and incident reports was completed to identify any additional unreported or uninvestigated allegations of abuse or neglect. Systemic Changes:All allegations are escalated same business day. APS, law enforcement, and legal representative notifications are completed within required timeframes. A standardized investigation process ensures documentation, findings, and corrective actions are retained. Education:Staff will be educated on mandatory reporting requirements, Police and authorities notification, investigation expectations, and documentation retention. Monitoring Frequency: Weekly audits of all allegations, investigations, and reporting actions. Documentation Method: Use of the Investigation & Reporting Audit Tool, documenting:APS reportingLaw enforcement notificationInvestigation stepsFindingsCorrective actionsRepresentative Sample: A rotating 10% sample of residents. Minimum Monitoring Duration: At least 3 months. Strategic Plan Integration: Daily Clinical Stand-Up and leadership review processes support ongoing compliance. Findings will be reviewed through the QAPI process monthly and reported to regional leadership.
9999Final ObservationsSurveyor note▼
Findings
THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.25.22 The assisted living residence shall meet the requirements of Part 13.10 regarding the internal grievance and complaint resolution process. In addition, the assisted living residence shall hold regular meetings to allow residents, their family members, friends, and representatives to provide mutual support and share concerns and/or recommendations about the care and services within each separate secure environment.(A) Such meetings shall be held at least quarterly, at a place and time that reasonably accommodates participation; and(B) The assisted living residence shall provide adequate advance notice of the meeting and ensure that details regarding any meeting are readily available in a common area within the secure environment.
Plan of correction
The state did not require a plan of correction for this citation.
4/20/2026Licensure Complaint · ID K0RT11No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A licensure complaint, prompted by #CO41437, was completed on 4/20/26. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
9/15/2025Revisit: Licensure Complaint · ID 5F9H12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 9/15/25 for all previous deficiencies cited on 5/27/25. 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.
6/9/2025Licensure Complaint · ID SWBI111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
An involuntary discharge appeal survey, prompted by #CO40298, was completed on 6/17/25. A deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1064Res Ad/D/C-D/C Res Dngr Slf/OthrsS/S B▼
Findings
Based on interviews and record review, the residence failed to reassess the resident to be discharged and revise his or her care plan to identify the resident's current needs and what services the assisted living resident will provide to meet those needs, affecting one resident (#1). Findings Include:1. Record ReviewOn 5/9/25, Resident #1 received a Discharge Notice from the residence stating "Resident requires a level of care that the Facility does not provide. The resident continually refuses treatment, care, food and exhibits signs of behavioral health conditions. The resident is refusing medication and refusing to eat meals which has left the resident malnourished. As a result of the resident's required level of care and concern for her safety, the Facility must terminate the Resident Agreement."On 6/10/25, at approximately 9:15 a.m., a request for documents from the administrator was made via email. The requested documents included care plans, progress notes showing efforts the facility took and measures to try and address the needs/circumstances related to the cause of the involuntary discharge, adult protection documentation, medication administration record (MAR), 30-Day Discharge Notice, Resident #1's grievance, residence's response to Resident #1's appeal, residence policy on Involuntary Discharge, Resident #1's signed Residential Agreement, medical documentation, resources that the residence provided assistance with housing search, Resident #1's demographic/facesheet information, and any complaints submitted by Resident #1. On 6/10/25, the requested documentation was received the requested documentation from the administrator, including care plans dated 5/31/24, 6/4/24, 9/27/24, and a copy of the written notice of termination dated 5/9/25, terminating the resident agreement between the residence and Resident #1. The discharge notice did not include interactions with the resident prior to the notice and actions that were taken to avoid discharge, specifying the timing of the events and actions. On 6/12/25, a request was made for additional documentation to include all practitioner-signed medication orders. The residence provided a copy of all practitioner-signed medication orders. On 6/24/25, a second request for all signed medication orders for Resident #1 to the Facility Administrator, specifically, the signed order for scheduled Morphine that was ordered 4/18/25. 2. InterviewOn 6/17/25 at approximately 11:48 a.m., the administrator stated that after a 3/31/25 outside provider visit, no new interventions were added, as Resident #1 continued to refuse care and was deemed capable of basic self-care. Additionally, had there been any changes or updates to Resident #1's care plan, all staff were updated on care plan changes during shift crossovers, but no interventions were added to the care plan post 3/31/25, outside provider visit.
Plan of correction · submitted by the facility
Community has updated process to reflect the requirements stated under 6 CCR 1011-1 Chapter 7 Part 11.17 inclusive of a detailed explanation for reasons of discharge, including facts and evidence supporting each reason given by residence and recounting of events leading to discharge. Community will ensure that practitioner assessment of resident’s current needs confirming that resident’s needs surpass what the community routinely provides are included in the involuntary discharge notice. The involuntary discharge notice will be reviewed to ensure the needed elements are present prior to issuance. Any resident identified as having a change of condition will be reassessed in accordance with MorningStar’s policy and procedures. This assessment will result in a new care plan that reflects the resident’s current needs. Leadership will conduct an in-service training for the community team to educate and reinforce the correct process, as outlined by MorningStar policy. Residents at risk for involuntary discharge will be added to community Resident At Risk report, this report is reviewed and updated weekly by the Executive Director and Wellness Director' it is then sent to the RVPW and RVPO. Residents, when appropriate, will be monitored for a minimum of 3-months. Residents being monitored as a potential involuntary discharge will be discussed as part of the community's monthly QAPI process. As part of the QAPI process the community team will evaluate the resident’s scope of care needs to ensure that the community can continue to provide quality and safe care to the resident. Prior to delivering any notice of involuntary discharge to all parties the Executive Director, Wellness Director, RVPW, and RVPO will review all documentation to ensure that the involuntary discharge has a detailed explanation and all required supporting documentation.
5/27/2025Licensure Complaint · ID 5F9H111 deficiency▼
0000Initial CommentsSurveyor note▼
Findings
A complaint survey, prompted by #CO40107, was completed on 5/27/25. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
1072Res Ad/D/C-D/C Invol D/C-Wrtn Ntc ReqS/S A▼
Findings
Based on interviews and record review, the residence failed to include in the initial 30-day involuntary discharge a detailed explanation of the reasons for the discharge, including interactions with the resident prior to the notice and actions that were taken to avoid discharge specifying the timing of the events and actions, affecting one resident (#1). Findings include:On 5/27/25 at approximately 9:07 a.m., the residence provided a copy of the written notice of termination dated 5/9/25 terminating the resident agreement between the residence and Resident #1. The discharge notice did not include interactions with the resident prior to the notice and actions that were taken to avoid discharge, specifying the timing of the events and actions. On 5/27/25 at 3:34 p.m., the administrator affirmed the residence did not included in the discharge notice, information detailing interactions with the resident prior to the notice and actions that were taken to avoid discharge, specifying the timing of the events and actions.
Plan of correction · submitted by the facility
Community has updated process to reflect the requirements stated under 6 CCR 1011-1 Chapter 7 Part 11.17 inclusive of a detailed explanation for reasons of discharge, including facts and evidence supporting each reason given by residence and recounting of events leading to discharge. Community will ensure that practitioner assessment of resident’s current needs confirming that resident’s needs surpass what the community routinely provides are included in the involuntary discharge notice. The involuntary discharge notice will be reviewed to ensure the needed elements are present prior to issuance. Residents at risk for involuntary discharge will be added to community Resident At Risk report, this report is reviewed and updated weekly by the Executive Director and Wellness Director' it is then sent to the RVPW and RVPO. Residents, when appropriate, will be monitored for a minimum of 3-months. Residents being monitored as a potential involuntary discharge will be discussed as part of the community's monthly QAPI process. As part of the QAPI process the community team will evaluate the residents scope of care needs to ensure that the community can continue to provide quality and safe care to the resident. Prior to delivering any notice of involuntary discharge to all parties the Executive Director, Wellness Director, RVPW, and RVPO will review all documentation to ensure that the involuntary discharge has a detailed explanation and all required supporting documentation.
5/7/2025Revisit: Licensure and Licensure Complaint (Combined) · ID HYOF12No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 5/7/25 for all previous deficiencies cited on 2/4/25. 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.
9999Final ObservationsSurveyor note▼
Findings
Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally
Plan of correction
The state did not require a plan of correction for this citation.
2/3/2025Licensure and Licensure Complaint (Combined) · ID HYOF113 deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A relicensure survey with complaint #CO36030, #CO36458, and #CO36527 was completed on 2/4/25. Deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0734Stf Req-First Aid 1 Stf Onsite CPRS/S B▼
Findings
Based on the interview and record review, the residence failed to ensure there was at least one staff member onsite at all times certified in cardiopulmonary resuscitation (CPR), affecting 66 current residents. Findings include:On 2/3/25 at 1:03 p.m., CPR certification for all staff was requested from the administrator. On 2/4/25 at 2:41 p.m., certifications were provided. However, the CPR certifications revealed several staff members listed on the schedule did not have CPR certification. The staff schedule revealed the overnight shift from 10:00 p.m. to 6:00 a.m. did not have a person onsite at all times certified in CPR on the following days: 1/3, 1/17, 1/24, and 1/31/25. On 2/4/25 at 2:35 p.m., the administrator, assistant executive director (AED), Staff #6, and Staff #7 acknowledged that the residence failed to provide CPR cards for the staff working during the 10:00 p.m. to 6:00 a.m. shift in the building.
Plan of correction · submitted by the facility
Immediate Action Intervention: Schedule adjusted immediately to ensure all shifts have a CPR Certified Team Member on all shifts and days each week. Intermittent Intervention: CPR Certification Training scheduled for 2/25/25 from 4:00pm to 8:00pm, with 23 Staff members to attend. Ongoing Intervention: CPR Certification training to be scheduled Quarterly moving forward. Q1 CR training scheduled for 2/25/25. Future CPR certification classes to be scheduled by ED/AED as the community experiences turnover to ensure adequate staff for scheduling to meet the regulations. Schedule and attendance to be reviewed with all Department Heads for compliance and scheduling. All New Hires Must attend next available CPR training. Running CPR Certification Roster to include date of current certification and Expiration Date. Audit of Team Members certification to occur Monthly and will be audited by both ED and AED in order to ensure compliance..
1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼
Findings
Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of seven sample residents (#6) and one former resident (#8). Findings include:1. Resident #6 was admitted to the residence on 1/13/25 with diagnoses including depression. A written practitioner's order dated 1/2/25 directed the residence to administer fluoxetine 10 mg once daily. However, the January 2025 medication administration record (MAR) for Resident #6 read the medication was not available and not administered on 1/17-1/22/25, for a total of six days. InterviewsOn 2/4/25 at 1:05 p.m., a family member of Resident #6 acknowledged the residence did not administer the medication to Resident #6 because she had brought in the wrong bottle. On 2/4/25, at 3:50 p.m., the wellness director stated that the residence did not administer Resident #6's fluoxetine from 1/17-1/22/25 because the family member had brought in the wrong bottle of medication. On 2/4/25 at approximately 3:30 p.m., the administrator said he expected the residence to administer residents medication and not run out of stock. 2. Similar deficient practice was also found for Former Resident #8.
Plan of correction · submitted by the facility
Immediate Intervention:Ensure all Residents Medications are available for all residents. Audit completed by Wellness Director on 2/20/2025, with no medications indicated as unavailable. Medication audits kept in compliance binder in wellness office. Intermittent Intervention: Prior to admission the community will obtain detailed, physician signed med list. Upon admission for all residents, medications supplied by the family will be cross referenced against the signed med list by Wellness Director or designee, medications supplied by community contracted pharmacy will be verified by pharmacy and Wellness Director or designee. Ongoing Intervention: Wellness Director, Wellness Nurse or designee will complete monthly 2 step (MAR to cart) and quarterly 3 step (chart to MAR to cart) medication review to ensure compliance. Monthly 2 step will be completed through August 31, 2025, quarterly 3 step med audit will be completed indefinitely as mandated by CDPHE regulations. Meds not available will be reviewed at daily clinical standup and root cause analysis completed during monthly QAPI.
3060Sec Env-Enhncd Rsdnt CP IncldS/S A▼
Findings
Based on record review and interview, the residence failed to have a care plan that included a description of the resident's known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident, affecting one sample resident (#6). Findings include:1. Resident #6 was admitted to the residence on 1/13/25 with diagnoses including Alzheimer's disease, hemorrhagic stroke, and major depressive disorder. Progress notes for Resident #6 in January 2025 revealed the following:Resident #6 fell on 1/18, 1/23 and 1/29/25. On 1/30/25 at 1:53 p.m., Resident #6 fell after sliding off his bed earlier in the day and wandered around without his walker or wheelchair. On 1/31/25 at 1:18 a.m., Resident #6 slid off his walker and fell to the floor. A care plan for Resident #6 was updated 1/29/25. The care plan did not include individualized approaches to be implemented by staff to prevent additional falls after Resident #6 fell on 1/30 and 1/31/25 InterviewsOn 2/4/25 at 1:05 p.m., a family member of Resident #6 said Resident #6 fell at home a lot and tried to walk when he was not physically able to. She added, at the residence he had a call pendant that he could push for staff assistance but he got confused and tried to walk by himself and fell. On 2/4/25 at 2:45 p.m., Staff #8 said after Resident #6 fell three times on 1/18, 1/23 and 1/29/25 the residence tried to get Resident #6 a call pendant so he could request staff assistance. Contrary to Resident #6's family member saying he already had one. On 2/4/25 at 2:45 p.m., Staff #9 said after Resident #6 fell three times on 1/18, 1/23 and 1/29/25, the residence requested staff check on Resident #6 more often and keep him in common areas for supervision. She added, no other individualized approaches were mentioned after he fell on 1/30 and 1/31/25. On 2/4/25, at approximately 4:00 p.m., the administrator acknowledged that he had not been aware that Resident #6 ' s care plan had not been updated following the most recent falls on 1/30 and 1/31/25. He further stated that individualized approaches needed to be added to the care plan, ensuring staff could implement measures to protect all residents from harm.
Plan of correction · submitted by the facility
Immediate Intervention:All care plans will be reviewed and updated with personalization on or before April 30, 2025. All care team members will be responsible for reviewing updated care plans to ensure care provided aligns with care planned. Intermittent Intervention:Behavioral Interventions for all residents to be reviewed by Wellness Director, Executive Director, and Care Coordinators for 3 residents weekly for 6 weeks, then to review 3 residents minimum monthly. Ongoing Intervention:Pre-admission, discovery to include more behavioral and secure environment related information relative to residents needs from both family and Resident’s Physician to ensure in depth interventions and historical failed interventions. Wellness Director or designee will ensure that all future care plans to be personalized to reflect the needs, wants, and desires of the resident. All future care plans to reflect interventions that align with all diagnosis.
9999Final ObservationsSurveyor note▼
Findings
THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 2 and 7.11.2.3. Facilities and agencies shall ensure that ninety percent (90%) of employees and direct contractors have received the influenza vaccine during a given influenza season. In order to demonstrate that the ninety percent (90%) rate has been meet, facilities and agencies shall: (A) By May 15th of every year, report to the Department, in the form and manner specified by the Department, the vaccination rate for employees and direct contracts for the most recent influenza season. (B) Have defined procedures to prevent the spread of influenza from unvaccinated healthcare workers. (C) Maintain for three (3) years the following documentation that may be examined by the Department in a random audit process: (1) Proof of immunization, as defined at Part 1.51 of this Chapter. (2) A medical exemption signed by a physician, physician assistant, advanced practice nurse, or certified nurse midwife licensed in the State of Colorado stating that the influenza vaccination for the employee or direct contractor is medically contraindicated as described in the product labeling approved by the FDA. 14.9. No medication shall be administered by a qualified medication administration person on a pro re nata (PRN) or "as needed" basis except: (A) In a residential treatment facility that is licensed to provide services for the mentally ill; (B) Where the resident understands the purpose of the medication, is capable of voluntarily requesting the medication, and the assisted living residence has documentation from an authorized practitioner that the use of such medication in this manner is appropriate; or (C) Where specifically allowed by statute. 18.8. Resident records shall contain, but not be limited to, the following items: (A) Face Sheet; (B) Practitioner order; (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. (E) Medication Administration Record; (F) Documentation of on-going services provided by external service providers including, but not limited to, caregivers, essential caregivers, aides, podiatrists, physical therapists, hospice and home care services, and other practitioners, assistants, and care providers; (G) Advance directives, if applicable, with extra copies; and (H) Final disposition of resident including, if applicable, date, time, and circumstances of a resident's death, along with the name of the person to whom the body is released. 25.5 Before an individual moves in, the assisted living residence shall complete a pre-admission assessment to determine the appropriateness and need for secure environment residency. The pre-admission assessment shall include all the items required for the comprehensive assessment in Part 12.7(A) through (M), plus the following: (A) An evaluation by a licensed practitioner which has occurred within the previous ninety (90) calendar days and which describes the resident ' s medical condition and any cognitive deficits that contribute to wandering, compromised safety awareness, and other types of conduct; and (B) Detailed information from the resident ' s family and/or representative concerning the resident ' s recent relevant history and patterns of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting, and any other known types of conduct.
Plan of correction
The state did not require a plan of correction for this citation.
2/8/2024Revisit: Licensure Complaint · ID 5KX112No deficiencies▼
0000Initial commentsSurveyor note▼
Findings
A revisit survey was completed on 2/8/24 for all previous deficiencies cited on 7/25/23. 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.
2/8/2024Revisit: Licensure Complaint · ID D2OG14No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 2/8/24 for all previous deficiencies cited on 7/25/23. 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.
2/8/2024Revisit: Licensure Complaint · ID IQN313No deficiencies▼
0000Initial CommentsSurveyor note▼
Findings
A revisit survey was completed on 2/8/24 for all previous deficiencies cited on 7/25/23. 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.
Reportable Occurrences
17 records4/23/2026Missing Person · ID 2623T231014Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/23/26, 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 a missing client. A community member returned client (A) to the facility and informed staff. Client (A) was an at-risk adult, exited the facility, and was missing for 30 minutes. During the course of the investigation, the healthcare entity contacted police, client (A)'s medical provider and their representative, reviewed records, and conducted interviews. Client (A) confirmed where they wanted to go in the community, but had fallen and gotten lost. Staff assessed and treated client (A)'s injuries. The facility implemented 1:1 supervision and discussed a higher level of care for client (A) with their representative. Since the report, client (A) moved out of the facility. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 7/21/2026 · released to the public 7/28/2026.
4/13/2026Misappropriation of Property · ID 2623T231005Reported on time: No▼
Occurrence summary
SUMMARY OF FINDINGS:On 4/24/26, 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. Client (A) reported that $63 was missing from their wallet and was unsure when it was last accounted for. During the course of the investigation, the healthcare entity conducted interviews. Other clients reported no missing items from their rooms. The facility re-educated staff about not accepting gifts from clients and ensuring their keys are secured. The facility educated client (A) on storing their valuables in a secure location. Due to the results of the investigation being inconclusive, 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 6/30/2026 · released to the public 7/7/2026.
4/11/2026Neglect · ID 2623T231004Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 5/27/26, the healthcare entity investigated a reportable event of neglect of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 5/27/26, Event ID M5T211. 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. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was not submitted within the required timeframe.
Publication
Sent to facility 6/12/2026 · released to the public 6/24/2026.
12/14/2025Neglect · ID 2523T231010Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 12/14/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a neglect event. Client (B) alleged staff left her food out of reach and due to her weakness, she could not retrieve the tray. Also, client (B) reported staff did not ensure she had adequate personal supplies in her room to meet her toileting needs. During the course of the investigation, the healthcare entity checked on the client’s product needs and conducted interviews. Management found she had adequate supplies in her room but noted her preference was for more paper products. A communication gap was identified with meal deliveries that resulted in two days when staff left her tray in the living room area versus her preference of her bedroom. There was no reported adverse outcome to client (B). A neglect event could not be 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 4/3/2026 · released to the public 4/10/2026.
9/27/2025Physical Abuse · ID 2523T231007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/29/25, 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 facility's camera footage revealed that client (A) lowered themselves to the floor, and staff (1) pulled them by their arm across the room and then attempted to lift them up by their arms. During the course of the investigation, the healthcare entity suspended staff (1), contacted police, and conducted interviews. Due to severe cognitive decline, client (A) could not communicate or recall details of the event. No visible injuries were observed when assessed. The facility could not get in contact with staff (1) for a follow-up, and their employment was terminated. The facility took the opportunity to retrain staff on transfer techniques, as staff (1) deviated from the lift assistance policies and procedures. The facility implemented two staff members to be present when assisting client (A) with care. As staff witnessed the incident via camera footage, 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 3/12/2026 · released to the public 3/19/2026.
9/21/2025Physical Abuse · ID 2523T231005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/21/25, 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 help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Staff reported client (B) grabbed client (A)'s arm, and when she attempted to pull her arm away, it caused a skin tear. Staff separated the two clients. During the course of the investigation, the healthcare entity contacted police and medical providers, assessed and monitored client (A)'s skin tear, conducted interviews, and updated care plans. Client (A) and client (B) could not recall details of the event due to cognitive impairment. The facility increased staff oversight in common areas and continued to keep client (A) and client (B) separated. 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 2/23/2026 · released to the public 3/2/2026.
9/21/2024Physical Abuse · ID 2423T231007Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 9/21/24, 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) walk past Client (A) and hit them in the face with a mug, and before Client (A) then tossed books at Client (B) hitting them. The clients were fighting over a chair. Staff provided increased oversight for the clients. The chair in question was removed when no staff were present as it is designated to assist this client (B). 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 5/28/2025 · released to the public 6/4/2025.
7/25/2024Physical Abuse · ID 2423T231005Reported on time: Yes▼
Occurrence summary
SUMMARY OF FINDINGS:On 7/25/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported 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) push Client (A) down to the ground. Client (A) had cognitive impairment and could not recall what happened to them. No visible injuries. Client (B) had increased safety checks implemented and their medications reviewed to assist with negative behaviors and territorial tendencies. Staff will ensure other clients are at a safe distance from Client (B). 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 4/25/2025 · released to the public 5/2/2025.
7/12/2024Misappropriation of Property · ID 2423T231004Reported on time: Yes▼
Occurrence summary
SUMMARY FINDINGS: On 7/12/24 Resident (A) stated while she was showering around 8:00 p.m.,$50.00 went missing from her drawer in her room. Resident (A) stated her drawer was messed up and gone through and that had never occurred before. The facility investigation concluded even with thorough interviews with staff, residents and visitors, no assailant was identified. To help prevent a recurrence, the policy was reviewed with residents to use a safe locked drawer.
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.
Publication
Sent to facility 1/30/2025 · released to the public 2/6/2025.
1/2/2024Physical Abuse · ID 2423T231002Reported on time: Yes▼
Occurrence summary
DESCRIPTION OF OCCURRENCE:On 1/2/24, Resident B disregarded and removed a visual aid that directed others not to enter the room of resident A. Resident A asked them to leave their room. Residents A and B slapped and struck each other, causing both of them to fall to the floor. Resident B sustained a skin tear from the altercation. The altercation was not witnessed, but was captured on a ring camera on the door of Resident A.FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family/guardians, ombudsman, physicians and Adult Protective Services. The residents were separated and staff checked on both residents. A nurse and emergency services personnel assessed resident B and the nurse provided a dressing to the skin tear on the left forearm. Resident A stated resident B had come into their room and was unable to recall any other part of the altercation due to poor memory recall and cognitive impairment. Resident B was unable to recall the altercation due to poor memory recall and cognitive decline. The facility concluded resident A had attempted to redirect resident B out of her room, and both residents believed the room was theirs, which resulted in a physical altercation. To help prevent a recurrence, resident A agreed to keep the door to their room secured with a visual aid in place, to prevent other wandering residents from entering their room. A care meeting was held to discuss resident B’s historical altercations and general decline. Resident B had a change of physician and a change of medications were made. Staff increased visual checks on resident B to eight times at night and four times during the day. A 1:1 was put in place for resident B, between the hours of 3:00 to 7:00 p.m. to reduce the risk for future altercations.
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.
Publication
Sent to facility 11/12/2024 · released to the public 11/19/2024.