PEARL AT BOULDER CREEK, THE

SUMMARY OF FINDINGS:On 4/27/26, 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) received a fraud alert from their bank regarding a voided personal check that was made out to the facility and dated 10/14/24. The personal check attempted to be endorsed by another individual who wrote their account information for deposit. During the course of the investigation, the healthcare entity supported client (A) with contacting their bank and representatives, reviewed records, and conducted interviews. The facility ensured the fraudulent personal check was not one they had on file for mobile deposit. Client (A) confirmed not locking their apartment when leaving and continued to refuse to lock it. Staff denied knowledge of client (A)'s checkbook or taking items from the room. The facility encouraged client (A) to store their valuables in a locked box. Client (A) and their representative worked with law enforcement and the bank's fraud department to identify an assailant. The investigation remained ongoing. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 7/1/2026 · released to the public 7/8/2026.

SUMMARY OF FINDINGS:On 11/17/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of a client. Client (A) alleged Staff #1 grabbed them and caused bruising to their wrists the previous evening. During the course of the investigation, the healthcare entity suspended Staff #1, assessed the client, notified law enforcement, and conducted interviews. Staff #1 reported Client (A) had grabbed Staff #1’s wrist after refusing medications, but they did not harm Client (A). The facility reported Client (A) utilized outside caregivers to mitigate safety concerns like increased anxiety. Client (A) continued on their care plan with private caregivers throughout the week. Staff #1 was still on administrative leave pending the outcomes of external investigations. The facility’s findings were inconclusive, and the event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 2/24/2026 · released to the public 3/3/2026.

SUMMARY OF FINDINGS:On 6/23/25, 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 misappropriation of client property. Client (A) alleged a pearl necklace and their engagement ring were missing from their closet. Client (A) thought they may have misplaced them, however they were not found. During the course of the investigation the healthcare entity conducted a search, and interviews. A number of individuals were in the clients apartment. Staff #1 who assisted with a shower made no entry into the closet area. The insurance company covered the costs to Client (A). The client was educated to secure their valuables. The police were notified and no assailant was identified. 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 8/27/2025 · released to the public 9/3/2025.

SUMMARY OF FINDINGS:On 3/2/25, 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 misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, and interviews. The client alleged $200.00 was missing from their apartment and they always kept their door locked. The family member believes the client may have spent it but can not confirm. The police were notified and no assailant was identified as all staff indicated they did not have any reason to enter the client's apartment. New locks were considered by the facility to be able to determine who entered through what doors. A safe was suggested to the client. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 5/2/2025 · released to the public 5/9/2025.

SUMMARY OF FINDINGS:On 1/17/25, 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 diverted drugs. During the course of the investigation the healthcare entity attempted to locate the missing medication. A possible five staff could have been involved with the one Clonazepam pill that was missing. All were negative for their drug test. There was no indication the medication was diverted intentionally. Staff #1 whose shift it was, was removed from medication duties until further notice. All staff participated in a training for medication administration and separating narcotics from other medications. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 7/24/2025 · released to the public 7/31/2025.

SUMMARY OF FINDINGS:On 7/26/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported diverted drugs. During the course of the investigation the healthcare entity attempted to locate the missing medication. The client did not miss any doses. Four staff were drug tested who had access to the missing medication without any findings pertinent to the missing medication. All staff were allowed to return to work after being suspended. Mandatory training was done, a delay in training new hires for a six month period, management oversight and audits will be conducted and the implementation of a communication book between staff. There had been miscommunication that made the medication appear discontinued. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Sent to facility 4/25/2025 · released to the public 5/2/2025.

SUMMARY FINDINGS: On 6/11/24 Resident (A) alleged $300.00 was missing from her room and she believed staff member (1) who assisted her with care had taken the money. Staff member (1) was suspended and terminated during this investigation for unrelated reasons. Resident (A)’s details of where the money may have gone changed multiple times, from staff to family. Staff notified the police who investigated the incident. The facility investigation concluded due to a lack of evidence could not confirm theft occurred. To help prevent a recurrence, management discussed with Resident (A) on measures to safeguard her valuables like a safe or storage that is off-site. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Sent to facility 1/16/2025 · released to the public 1/23/2025.

DESCRIPTION OF OCCURRENCE: On 2/5/24 it was identified four pills of resident (B) were missing and replaced with resident (A)’s medication. There were potentially three staff members (1), (2) and (3) involved. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. Staff members (1) and (2) had direct involvement and staff member (3) was indirectly involved. No harm to resident (A) from having his medications taken he had more. Resident (B) offered staff member (1) his medication to replace the medication that he had given to staff member (2) for personal use. All stories confirm the same outcome. The facility investigation concluded staff members (1) and (2) intentionally removed resident (A)’s medications from the bottle they were in. To help prevent a recurrence, staff members (1) and (2)'s employment were terminated. Staff member (3) was removed from all medication duties for 30 days and until they were recertified. A probationary period was to follow. No staff should work the medication card two shifts in a row. Narcotics will be locked until they are to be administered and returned to the locked area immediately after. Staff are to monitor tablet discrepancies at shift change to identify tablets that do not match. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 11/26/2024 · released to the public 12/3/2024.

DESCRIPTION OF OCCURRENCE: On 1/19/24, resident (A) in her 70s alleged that her prescribed anti-depressant medication, Trazodone 100mg was taken from her apartment. She was unaware how many tablets were missing due to combing multiple anti-depressant medication bottles together. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police and physician. On 1/19/24, resident (A)'s therapist suggested staff begin managing resident (A)’s medication and the resident agreed. When resident (A) requested her anti-depressant medication from a staff member on 1/19/24, she was told the order wasn't carried out yet. The staff did not have her medication. Resident (A) found another bottle with enough tablets in it until the new order was received and processed. The other bottle remained missing. Staff searched resident (A)’s apartment and the facility medication storage area to ensure resident (A) didn't hand her medication to any staff. The therapist stated they did not remove the medication from resident (A)’s apartment. Resident (A) stated an agency staff member (1) assisted her with dressing and must have taken her medication. Staff member (1) was suspended pending the investigation. Staff member (1) denied the allegation. She did not enter resident (A)’s apartment. Resident (A) also thought she may have thrown away the bottle of anti-depressant medication. The facility investigation determined it was unclear if the mediations were stolen or if resident (A) disposed of them by accident. To help prevent a recurrence, staff would manage ordering and administration of the medication to resident (A) and ensure it's taken appropriately. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 11/19/2024 · released to the public 11/26/2024.