COMMONS OF HILLTOP, THE — Colorado Facility Report

Inspections

Deficiencies

Actual Harm or Above

Occurrences

January 21, 2026

Last Inspection

S/S B Minimal potential

The most recent inspection of COMMONS OF HILLTOP, THE on record is dated January 21, 2026. Across 5 published inspections, state surveyors cited 6 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/Alternative Care Facility (Medicaid)

Administrator

BOYER, TIMINDRA

Owner

HILLTOP HEALTH SERVICES CORPORATION

Phone

(970) 243-3333

Payor Source

Medicaid, Private Pay

City

GRAND JUNCTION

ZIP

81506

Inspections & Citations

5 inspections · 6 deficiencies

1/21/2026Revisit: State Certification (Re-certification) · ID ZNW812No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 1/21/26 for all previous deficiencies cited on 9/23/25. 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.

1/21/2026Revisit: Licensure (Re-licensure) · ID ZXEN12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 1/21/26 for all previous deficiencies cited on 9/23/25. 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.

9/23/2025State Certification (Re-certification) · ID ZNW8112 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A recertification survey was completed on 9/23/25. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0920PA Req-Med Admin-Rx/PRN▼

Findings

Based on records review and interviews, the facility (residence) failed to ensure that a member's (resident's) refusal to take medications was reported to the resident's licensed medical provider (authorized practitioner), affecting two of eight residents who reside in the secure environment (#6, #7). Findings include:1. Record ReviewResident #7 was admitted to the residence on 9/1/21 with a diagnosis of dementia. A practitioner's order dated 4/24/25, read that the residence was to administer acetaminophen 500mg three times daily. A medication administration record (MAR), dated 8/6/25, 8/10/25, 8/14/25, 8/18/25, and 9/21/25 read that Resident #7 refused the acetaminophen despite being asked several times. A request for refusal notification forms to the practitioner were requested on 9/23/25, however the residence did not have any. 2. Similar deficient practice was found for resident #6. 3. InterviewsOn 9/23/25 at 5:11 p.m., the administrator stated the residence did not reach out to the practitioner when Resident #6 and #7 were refusing their medication and stated she would expect her staff to reach out to the practitioner each time a resident refused their prescribed medication.

Plan of correction · submitted by the facility

The Medication Office Coordinator is re-implementing the missed medication form process. Part of the process is to notify the physician when a resident has a pattern of refusing a medication. The Medication Office Coordinator will monitor and report her findings monthly at QMP. QMAPS will keep records of faxes, and the medication office coordinator will report to the QMP leadership her findings for the next three months and we will evaluate the process and the continued needs. Addendum: 11/7/2025Corrective action of Resident #6 & #7 was notification to physician of the refusal of their medications. Physician orders were followed, no discharge was needed. The notification of physician was added to the training checklist for all new QMAP hires. Retraining of current QMAP's began on 9/23/2025, following the on-site survey.

1710Ben/Svc Req-ACF-Inclusions▼

Findings

Based on records review and interviews, the facility (residence) failed to conduct an assessment before admission that documented that the setting would support the member (resident) and their needs, as well as develop the resident's care plan with appropriate supports identified to enable as independent a life as possible, affecting two of eight residents who reside in the secure environment (#6, #7). Findings Include:1. Record ReviewResident #6 was admitted to the residence on 9/18/23 with a diagnosis of dementia. Resident #7 was admitted to the residence on 9/1/21 with a diagnosis of dementia. On 9/23/25 at 2:24 p.m., a request for the pre-admission practitioner assessment was requested. A practitioner assessment was found for Resident #6, but not for Resident #7. The assessment provided for Resident #6, dated 7/8/24, failed to include her cognitive deficits that contribute to wandering, compromised safety awareness, and any other types of conduct. The assessment also failed to include detailed information from Resident #6's family 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 other known types of conduct. 2. InterviewsOn 9/23/25 at 4:46 p.m., the administrator stated she was aware of the required elements for the pre-admission practitioner assessment, confirmed the residence could not find an assessment for Resident #7, and acknowledged that the assessment the residence received from Resident #6 was lacking in the required elements and would expect that moving forward, the residence had a more robust practitioner pre-admission assessment.

Plan of correction · submitted by the facility

The facility will audit all current secured residents to ensure proper pre-admission assessment paperwork was complete. During the audit process if any other residents are found to not have the proper paperwork, it will be corrected by notifying all appropriate parties to obtain the appropriate paperwork. A documented re-training with Admission / Memory Care Coordinator will take place to ensure the proper procedure is being upheld. POC going forward, a member of QMP will need to sign off all new admissions into the secured unit to verify that all pre-admission assessment requirements are met prior to moving in.

9/23/2025Licensure (Re-licensure) · ID ZXEN114 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey was completed on 9/23/25. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1596Med/Med Adm-Med Prep/Hnd Tr ICS/S B▼

Findings

Based on observations and interviews, the residence failed to ensure that qualified medication administration persons (QMAP) applied nationally recognized protocols for basic infection control and prevention when preparing and administering medication, affecting four of four residents observed during medication administration (#13, #14, #15, #16). Findings Include:1. ObservationsDuring medication administration on 9/23/25 from 8:42 a.m. to 9:18 a.m., Staff #5 failed to perform proper hand hygiene between residents. Staff #5 donned gloves, then administered medications and eye drops to Resident #13. After completing the task, Staff #5 doffed their gloves. Without performing hand hygiene, Staff #5 proceeded to administer medications to Resident #14. Staff #5 then donned gloves again, administered medications to Resident #15, applied prescribed creams to both his legs and arms, and administered eye drops in both of his eyes. Staff #5 then doffed their gloves. Following this, Staff #5 administered medications to Resident #16. Staff #5 failed to perform handwashing or use hand sanitizer between residents' medication administration. 2. InterviewsOn 9/23/25 at 9:23 a.m., Staff #5 stated that she should have washed her hands after administering prescribed eye drops and creams to the residents. She acknowledged that she had not washed her hands and admitted that she should have done so. She stated that she had been trained in basic infection control and prevention procedures related to medication preparation and administration. Staff #5 also stated that she should have used hand sanitizer between each resident and washed her hands with soap and water after every third resident. On 9/23/25 at 4:25 p.m., the administrator explained that the residence's process for handwashing during medication administration was for staff to wash their hands with soap and water before entering and after exiting a resident's room if the resident was in isolation due to an illness. She explained that if the resident was not in isolation due to an illness, she expected staff to either sanitize or wash their hands after administering medications. The administrator stated that staff had been trained in basic infection control and prevention procedures related to medication preparation and administration. She agreed that staff were not following the residence's handwashing process after administering medications, eye drops, and creams, and stated that she would expect them to.

Plan of correction · submitted by the facility

Staff #5 was counseled after the surveyors left. Staff #5 expressed being nervous during the shadowing and has stated that she knows the correct techniques. The plan to correct will be to continue to teach all employees the nationally recognized infection prevention and handwashing techniques. We will implement competency observations on all QMAPs and The Medication Office Coordinator will ensure the proper hand washing techniques are followed by implementation of competency observations. The Medication Office Coordinator will attend monthly QMP meetings for the next 3 months and report any trends that are being observed, and we will evaluate continued needs after three months. Addendum: 11/7/2025Competency Observations will be documented on a form by the Medication Office Coordinator, QMAP Supervisor, or other Care Department Leadership members. The observations will occur once a week for the next three months.

1612Med/Med Adm-Rprt Pract/Rep NtfdS/S B▼

Findings

Based on records review and interviews, the residence failed to ensure that the resident's authorized practitioner was promptly notified of the resident's pattern of refusal of prescribed medications, affecting two of two sample residents who resided in the secure environment (#6, #7). Findings include:1. Record ReviewResident #7 was admitted to the residence on 9/1/21 with a diagnosis of dementia. A practitioner's order dated 4/24/25, read that the residence was to administer acetaminophen 500mg three times daily. A medication administration record (MAR), dated 8/6/25, 8/10/25, 8/14/25, 8/18/25, and 9/21/25 read that Resident #7 refused the acetaminophen despite being asked several times. A request for refusal notification forms to the practitioner were requested on 9/23/25, however the residence did not have any. 2. Similar deficient practice was found for resident #6. 3. InterviewsOn 9/23/25 at 5:11 p.m., the administrator stated the residence did not reach out to the practitioner when Resident #6 and #7 were refusing their medication and stated she would expect her staff to reach out to the practitioner each time a resident refused their prescribed medication.

Plan of correction · submitted by the facility

3030Sec Env-Pre Adm AsS/S B▼

Findings

Based on records review and interviews, the residence failed to complete a pre-admission assessment to determine appropriateness and need for secure environment residency that included all required elements, affecting two of two sampled residents who resided in the secure environment (#6, #7). Findings include:1. Record ReviewResident #6 was admitted to the residence on 9/18/23 with a diagnosis of dementia. Resident #7 was admitted to the residence on 9/1/21 with a diagnosis of dementia. On 9/23/25 at 2:24 p.m., a request for the pre-admission practitioner assessment was requested. A practitioner assessment was found for Resident #6, but not for Resident #7. The assessment provided for Resident #6, dated 7/8/24, failed to include her cognitive deficits that contribute to wandering, compromised safety awareness, and any other types of conduct. The assessment also failed to include detailed information from Resident #6's family 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 other known types of conduct. 2. InterviewsOn 9/23/25 at 4:46 p.m., the administrator stated she was aware of the required elements for the pre-admission practitioner assessment, confirmed the residence could not find an assessment for Resident #7, and acknowledged that the assessment the residence received from Resident #6 was lacking in the required elements and would expect that moving forward, the residence had a more robust practitioner pre-admission assessment.

Plan of correction · submitted by the facility

3060Sec Env-Enhncd Rsdnt CP IncldS/S B▼

Findings

Based on records review and interviews, the residence failed to include all required elements of the resident's care plan who resided in the secure environment, affecting two of two sampled residents who resided in the secure environment (#6, #7). Findings Include:1. Record ReviewResident #6 was admitted to the residence on 9/18/23 with a diagnosis of dementia. Resident #7 was admitted to the residence on 9/1/21 with a diagnosis of dementia. On 9/23/25 at 2:31 p.m., a request for the enhanced care plans were requested for Residents #6 and #7. A care plan with an effective date of 9/18/25 to present read in part:that Resident #6 needed a two-person assist with bathing ... "WATCH YOUR APPROACH." The residence's care plan failed to include wandering patterns and known behavioral expressions along with individualized approaches to be implemented by staff to protect the resident. The plan also did not include a description of how the resident will have continuous independent access to her individual room and how to protect her from an unwanted visitor. The care plan also did not identify and detail the type and level of oversight, monitoring, and/or accompaniment to meet the need of the resident within the secure environment and the secure outdoor area. Lastly, the residence failed to include documentation describing if the hygiene items are safe for the resident to have in their own possession for self care and how those items are stored to prevent unauthorized access by other residents. 2. Similar deficient practice was found for resident #7. 3. InterviewsOn 9/23/25 at 4:53 p.m., the administrator stated she was aware of the of the required elements for the enhanced care plan and acknowledged the care plans in place for Resident and Resident #7 were lacking in the required elements and would expect that moving forward the residence had a more detailed care plan moving forward.

Plan of correction · submitted by the facility

The facility will audit all current secured residents to ensure enhanced care planning is conducted. Care Plans will be updated to ensure adherence to enhanced care plan requirements. A documented re-training with Admission / Memory Care Coordinator will take place to ensure the proper procedure is being upheld. POC going forward, a member of QMP will need to sign off all enhanced care plans to verify that all requirements are met. Addendum: 11/7/2025Residents #6 & #7 were a part of the above audit. Care Plans were updated to include all enhanced care plan requirements. Monitoring will take place for the next 3 months, upon which reevaluation for continued monitoring needs take place.

9999Final ObservationsSurveyor note▼

Findings

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.22 Only appropriately skilled professionals may train personal care workers and their supervisors on specialized techniques beyond general personal care and assistance with activities of daily living as defined in these rules. (Examples include, but are not limited to, transfers requiring specialized equipment and assistance with therapeutic diets). Personal care workers and their supervisors shall be evaluated for competency before the delivery of each personal service requiring a specialized technique.(A) Documentation regarding competency in specialized techniques shall be included in the personnel files of both personal care workers and supervisors.(B) A registered nurse who is employed or contracted by the assisted living residence may delegate to a personal care worker in accordance with the Nursing Practice Act if the registered nurse is the supervising nurse for the personal care worker."14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing. 14.35 The assisted living residence shall review this list with the resident and authorized practitioner at least once a year and maintain documentation of such review.

Plan of correction

The state did not require a plan of correction for this citation.

4/27/2023Revisit: Licensure (Re-licensure) · ID 4ODW12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 4/27/23 for all previous deficiencies cited on 11/2/22. The facility is in compliance with all deficiencies 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.

Reportable Occurrences

8 records

12/4/2025Brain Injury · ID 2523T695003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/4/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. Client (A) had an unwitnessed fall. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital. The client’s care plan was updated to reflect safety interventions to include: additional support as needed when the client returned from the hospital. 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 3/9/2026 · released to the public 3/17/2026.

4/24/2025Physical Abuse · ID 2523T695002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/24/25, 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. During the course of the investigation the healthcare entity ensured Client (A) and the alleged assailant (visitor #1) were separated before the police were notified. Staff heard yelling and screaming and spoke to Client (A) who indicated Visitor slapped them in the face on their left side. Client (A) was assessed without any visible marks. The visitor admitted to slapping the client and stated it was in self defense. The visitor has been provided with local support to receive dementia training and a meeting will be held to discuss if the visitor could return to the facility. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/17/2025 · released to the public 9/25/2025.

10/13/2024Brain Injury · ID 2423T695005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/14/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, obtained medical treatment and updated the client's care plan to reflect safety changes when using their wheelchair. 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 2/6/2025 · released to the public 2/13/2025.

9/25/2024Brain Injury · ID 2423T695004Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 9/25/24 staff identified resident (A), on hospice services, in need of care. Resident (A) verbally responded to staff agreeing to receive assistance from them. Resident (A) stood from a lying position and fell forward after becoming unsteady. Resident (A) struck his head as staff attempted to assist him to the floor during his fall. Emergency services were called as resident (A) had blood coming from his mouth, shallow breathing and was unresponsive. The facility investigation concluded resident (A) had a witnessed fall, sticking his head, and was later pronounced by the emergency services to be deceased at the facility. Resident (A) passed from natural causes as reported by the coroner. Current fall protocols were reviewed and will continue to be implemented by staff for all residents. 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 12/3/2024 · released to the public 12/10/2024.

8/18/2024Brain Injury · ID 2423T695003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 8/27/24, 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 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 clients care plan was updated to reflect safety interventions to include: additional safety checks, assistance with transfers and reminders to call for assistance. 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 2/4/2025 · released to the public 2/11/2025.

5/9/2024Brain Injury · ID 2423T695001Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 5/12/24 the facility was made aware resident (A) had a brain injury from their fall on 5/9/24. Resident fell on 5/9/24 in the dining room, hit her head and was immediately assessed by staff. Resident (A) was sent to the hospital for an evaluation and treatment. Resident (A) returned to the facility after receiving treatment at the hospital. The facility investigation concluded staff acted appropriately when resident (A) fell. To help prevent a recurrence, the care level has been increased to include more frequent checks for resident (A). They will be reminded by staff to slow down when walking and have been added to the fall management for review and monitoring. 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 12/2/2024 · released to the public 12/9/2024.

12/7/2023Sexual Abuse · ID 2323T695002Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 12/7/23, staff reported they suspected the family member of Resident A in her 70’s, was abusing her. The staff stated that when he visited, he took her to her apartment, instructed staff not to enter the room, shut off all the lights and got into bed with the resident. The staff reported they heard Resident A hollering when he was in the room with her, and when they responded they did not observe physical or sexual abuse. The staff reported the resident had a recent change of condition, as she was becoming combative when they attempted to provide her incontinence care and dressing assistance. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, ombudsman, physician and Adult Protective Services. The staff were directed to enter the resident’s room to provide care or to administer medications, as necessary, despite the family member’s instructions not to enter the room. The staff were directed to notify the police and an administrative staff member if any abuse was witnessed or if the family member became hostile. The resident had a diagnosis of Alzheimer’s disease and was cognitively impaired. The resident denied that there was any wrongdoing or fear of her family member. A medication review revealed some of her medications were discontinued and her physician was notified about the change of condition. The facility was informed the investigations completed by the police and Adult Protective Services did not reveal illegal activity or abuse. From the investigation, the facility was unable to determine if the allegation of sexual abuse was substantiated. To help prevent a recurrence, hospice care services were ordered for Resident A to receive a higher level of scheduled care. Staff were to call law enforcement and the administrator if the family member became agitated or if they witnessed any form of abuse. 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 11/7/2024 · released to the public 11/14/2024.

6/6/2023Brain Injury · ID 2323T695001Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 6/6/23, staff found a resident (A) in her 70s on the floor in her apartment next to her bed. Staff observed a large bump along with bruising surrounding her eyes, and a few skin tears. Resident (A) stated she was trying to get in bed and hit her head on her transfer pole. Staff reported finding resident (A)’s plant knocked over, her socks were off, medications were on the electric wheelchair, and her manual wheelchair was away from her. She was sent out to the hospital for an evaluation. Diagnostic test results showed a diagnosis of a brain bleed, and she was admitted to the intensive care unit for monitoring. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family/guardian and physician. When reviewing the events of the fall, the facility concluded the resident transferred herself without calling for assistance and suffered a fall with injuries. Per her safety plan, she was supposed to call for staff assistance. If the resident returned, a reassessment would occur to review her safety and care needs. Staff would enforce the need to call for staff 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.

Publication

Sent to facility 3/4/2024 · released to the public 3/4/2024.