JERUSALEM ASSISTED LIVING FACILITY

SUMMARY OF FINDINGS:On 11/15/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a missing client. An at-risk client signed out and left the facility, but did not return for approximately one week. During the course of the investigation, the healthcare entity notified law enforcement, contacted the client’s guardian, and conducted a search of the grounds. The facility reported the client went to a family member’s house while away. The client also declined an assessment following their return, but the facility stated the client was behaving normally and had no visible injuries. The facility contacted the client’s medical provider for a referral after the elopement, and the client’s care plan was updated to include a cell phone when leaving 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.

Sent to facility 1/6/2026 · released to the public 1/13/2026.

SUMMARY OF FINDINGS:On 6/8/25, 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 missing person. An at risk client was found to be missing when staff checked on them in the morning. During the course of the investigation, the healthcare entity notified law enforcement and the case manager, and attempted to contact the client. Four days later, the client’s mother reported to the facility that the client had returned to their mom’s home. The client indicated they would not return to the facility for a few days in order to stay with their mother, and came and picked up their medications. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 10/28/2025 · released to the public 11/4/2025.

SUMMARY OF FINDINGS:On 5/24/25, 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 the clients were separated before the police were notified. Staff witnessed Client (B) break property, punch staff before attacking Client (A) with a rock. Client (A) was sent to the hospital and treated for a fractured hand and a skin tear to their face before returning to the facility. Client (B) was removed from the facility by police and placed in a detention center. They were not allowed to return to the facility for the safety of others and was discharged from 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.

Sent to facility 11/4/2025 · released to the public 11/11/2025.

SUMMARY OF FINDINGS:On 8/19/24, 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 missing client. During the course of the investigation the healthcare entity conducted a search, interviewed staff and notified the police. The client signed out to go to the local convenient store and did not return to the facility. The client was not found at the time of this report. The event was substantiated. Follow-up, the client was found after a week at a local hospital. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.

Sent to facility 3/12/2025 · released to the public 3/19/2025.