LODGE AT GRAND JUNCTION, THE — Colorado Facility Report

Inspections

Deficiencies

Actual Harm or Above

Occurrences

June 16, 2026

Last Inspection

S/S B Minimal potential

The most recent inspection of LODGE AT GRAND JUNCTION, THE on record is dated June 16, 2026. Across 9 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 (Licensed Only)

Administrator

, Pending new admin

Owner

VOP GRAND JUNCTION LLC

Phone

(970) 822-4141

Payor Source

Private Pay

City

GRAND JUNCTION

ZIP

81506

Inspections & Citations

9 inspections · 6 deficiencies

6/16/2026Licensure (Re-licensure) · ID UKFQ11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

An administrative relicensure survey was completed on 6/26/26. No deficiencies were cited.

Plan of correction

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

4/15/2026Licensure Complaint · ID I6FV11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO42052, was completed on 4/15/26. No deficiencies were cited.

Plan of correction

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

1/6/2026CHOW and Licensure Complaint (Combined) · ID HNZ311No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO41261, was completed on 1/6/26. No deficiencies were cited. A change of ownership occurred on 10/7/24.

Plan of correction

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

2/3/2025Revisit: Licensure (Re-licensure) · ID 467813No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 2/3/25 for all previous deficiencies cited on 10/1/24. 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.

2/3/2025Revisit: Licensure and Licensure Complaint (Combined) · ID V68Y12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 2/3/25 for all previous deficiencies cited on 10/1/24. 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.

10/1/2024Revisit: Licensure (Re-licensure) · ID 4678122 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 10/1/24 for the previous deficiency cited on 4/26/22. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24. Tag 10.1 was not cited in the previous event; however, the deficiency was included in the previous event's informational 999 tag.

Plan of correction

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

0910Em Pr-Pol/Proc Res RstrS/S B▼

Findings

Based on observation, record review and interview, the residence failed to have readily available a roster of current residents which included the residents' emergency contact information and a diagram of the residence that showed room location, affecting 48 current residents. Findings include: On 10/1/24 at 7:30 a.m., the residence's official resident roster was requested. The roster included the full names of the residents and their room numbers. The resident roster did not include emergency contact information for the residents nor a diagram of the residence. On 10/1/24 at 4:45 p.m., the administrator stated she was unaware of the required components of the resident roster. The administrator added that she had a book of face sheets that could be provided in the event of an emergency that had the required emergency contact information. She acknowledged the resident roster was missing the residents' emergency contact information and a diagram of the residence. The administrator stated this deficiency that was previously an informational tag was not corrected due to lack of oversight and knowledge of the required components of a resident roster.

Plan of correction · submitted by the facility

Preparation and execution of this Plan of Correction does not constitute an admission or agreement by the provider of the truth, of the facts alleged or conclusions set forth in the statement of deficiencies. Self-Determination:Areas of concern cited in the recent 10/01/24 re-visit survey have been recognized and practices have been /and will be implemented to ensure the Lodge at Grand Junction will adhere to the following Plan of Correction (POC). Identification of Others:It is believed this deficient practice could have negatively impacted the Residents at the Lodge of Grand Junction. The Administrator began reviewing the Facility Emergency Preparedness program slated for The Lodge. Also recognizing the facility had not followed adequate standards in providing a Resident Roster as per standard requiring emergency contact numbers for Residents on roster. Although, the facility did have available contact information at the Med rooms, in a binder easily accessible. Corrective Action:Administrator and IDT, have reviewed the Emergency Preparedness Red Binder, kept at front desk, this has included current listings of Resident names, location, emergency contact information, room number, and evacuation status. Facility diagram has been updated to better show room numbers, making them legible, this diagram will also be kept in Red Binder for easy access. Concierge will continue to update Resident names and roster. Sustainability,Administrator will bring forward current copies of Resident roster, over the next 90 days submitting through QMP process. The administrator will continue to monitor QMP quarterly to ensure compliance continues to be met.

1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based upon record review and interview, the residence failed to ensure medication cart audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting 48 current residents. This deficiency was cited previously during a state licensure survey 8/18/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include 1. ReferencesThe residence's 12/1/23 medication records policy read in part that medication records would be audited on a quarterly basis. On 10/1/24 at approximately 9:30 a.m., the controlled substance list was requested and not received during the onsite visit. On 10/1/24 at approximately 1:40 p.m., documentation of quarterly medication audits were reviewed, and there was no evidence that the administrator participated in the audit. 2. Interviews On 10/1/24 at approximately 1:40 p.m., the resident care coordinator stated she often completed medication cart audits; however, the administrator did not participate on a quarterly basis. On 10/1/24 at 4:45 p.m., the administrator stated she oversaw all aspects of the residence but felt quarterly medication audits did not need to be completed by the administrator in case of probable liability issues with medications. The administrator acknowledged that she, along with the QMAP supervisor, did not participate in medication audits on a quarterly basis. The administrator stated this deficiency that was previously cited was not corrected due to lack of oversight and personal liability issues.

Plan of correction · submitted by the facility

Self Determination:Areas of concern cited 10/1/24, The Administrator failed to follow Regulation as it pertains to Medication audits., Although Administrator does ensure audits are conducted monthly by the Pharmacy, and audited consistently by Lead MAP’s, the Administrator failed to oversee audit, and signature sign off. Identification of Others:It is believed this deficient practice could have negatively impacted the Residents at the Lodge of Grand Junction. Corrective Action:The Administrator and the RCC will conduct a quarterly audit of medication carts, charts, and back stock, and will document any discrepancies. The Administrator will sign off as well as the RCC will sign off on Medication audits quarterly when conducted by Pharmacy and noted. RCC has been educated on the urgency to provide requested information to the Survey team when requested..Sustainability:The Administrator will bring forward monthly to QMP, and report any concerns, or Action Plans to further correct over the next 90 days and quarterly forward to ensure continued compliance.

10/1/2024Revisit: Licensure Complaint · ID BJVD12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 10/1/24 for all previous deficiencies cited on 8/18/22. The residence is in compliance with all regulations surveyed.

Plan of correction

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

10/1/2024Licensure and Licensure Complaint (Combined) · ID V68Y114 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey with complaint #CO29987 was completed on 10/1/24. Deficiencies were cited.

Plan of correction

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

0001Survey DetailsS/S B▼

Findings

"12.2.2 Infection Control Officer Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following: (1) (2) Completing an infection prevention and control training from a nationally recognized provider or the Department's training program within two (2) weeks of appointment/designation that meets the following requirements based on facility type."Based on record review and interview the residence failed to assign at least one staff member responsible for the site management of the residence's Infection Prevention and Control Program and who had completed an infection prevention and control training two weeks after designation, affecting 48 current residents. Findings include:1. ReferencesThe residence's 12/1/23 Infection Control policy read in part: the resident care coordinator (RCC) was responsible for monitoring the on-going compliance with the residences infection control policies. On 10/1/24 at 7:45 a.m., the designated infection prevention and control personnel's certificate of completion was requested and not received. 2. InterviewsOn 10/1/24 at 8:57 a.m., the administrator stated she and the RCC worked together to ensure the infection prevention and control procedures were implemented; however, neither one of them completed the infection prevention and control program training nor had a certificate of completion.

Plan of correction · submitted by the facility

Preparation and execution of this Plan of Correction does not constitute an admission or agreement by the provider of the truth, of the facts alleged or conclusions set forth in the statement of deficiencies. The Plan of Correction is prepared and/or executed solely because it is required by the provisions of Federal and State Law. For the purposes of any allegations, the facility is not in compliance with Federal requirements of participation, the response constitutes the facilities allegations of compliance in accordance with Chapter 7 and company policy. Self-Determination:Areas of concern cited in the 10/01/24 Survey have been recognized and practices have been/and will be implemented to ensure the Lodge at Grand Junction will adhere to the following Plan of Correction (POC). Identification of Others:It is believed these deficient practices could have negatively impacted the Residents at the Lodge of Grand Junction. This Administrator began reviewing the requirement to assign at least one person responsible for the site management of the Resident’s infection Prevention and Control Program. It was noted however, the Administrator does manage and oversee all aspects of the Infection Control process in the absence of a certified RCC/RCD, line-listing, PPE storage, and provided recent training for QMAPS on PPC proper donning and doffing, hand hygiene. Items also recently discussed in ALL Staff meetings, and in Orientation. Fit testing is completed upon hire. It was further noted, RCC recently, promoted to position and training was in process. Previous RCD was Certified, (but terminated 7/24). Administrator has obtained, ICP Certification, However, delegation to the RCC, to be completed 10/31/24.

0910Em Pr-Pol/Proc Res RstrS/S B▼

Findings

Plan of correction · submitted by the facility

Self-Determination:Areas of concern cited in the recent 10/01/24 re-visit survey have been recognized and practices have been /and will be implemented to ensure the Lodge at Grand Junction will adhere to the following Plan of Correction (POC). Identification of Others:It is believed this deficient practice could have negatively impacted the Residents at the Lodge of Grand Junction. The Administrator began reviewing the Facility Emergency Preparedness program slated for The Lodge. Also recognizing the facility had not followed adequate standards in providing a Resident Roster as per standard requiring emergency contact numbers for Residents on roster. Although, the facility did have available contact information at the Med rooms, in a binder easily accessible. And, facility did provide Resident roster, as well as facility mapping. The mapping room numbers were small and difficult for Surveyors to read. Administrator recognized these areas of concern. Corrective Action:Administrator and IDT, have previously reviewed the Emergency Preparedness Red Binder, kept at front desk, and multiple accessible areas of the facility. An updated, Red Binder will be drafted to ensure all areas of binder/policy are addressed. Including current listings of Resident names, location, emergency emergency contact information, room number, and evacuation status. Facility diagram has been updated to better show room numbers, making them legible, this diagram will also be kept in Red Binder for easy access. Concierge will continue to update Resident names and roster. Mapping will include, fire extinguisher locations, pull alarms,Resident council is educated on the Fire alarm and evacuation processes for/during each fire drill. and will continue quarterly. Staff are also educated monthly on Emergency Preparedness processes, will ensure education is provided again at all staff 10/31/24, A walk-through will be conducted to ensure instruction. Staff are familiar with our Walkie-Talkie communication system, and need to wear for emergency. Staff have been educated on Emergency systems and processes during All Staff meetings, and upon orientation by BSD.MOU/will be drafted with sister (Solstice) buildings as planned, this will also allow for transportation from one facility to the next. Both Solstice buildings will have adequate space. Sustainability,Administrator will bring forward current copies of Resident roster, over the next 90 days submitting through QMP process. The administrator will continue to monitor QMP quarterly to ensure compliance continues to be met. The Administrator and IDT will continue to draft processes for evacuation and conduct training for Staff and Residents, to further incorporated additions.. 10/31/24Over the next 90 days, processes will be reviewed through QMP, and will continue to be monitored quarterly to ensure maintenance of performance.

0920Em Pr-Pol/Proc Em Pol/Proc-Min ReqS/S B▼

Findings

Based on record review and interview, the residence failed to ensure its emergency policies addressed written agreements with other facilities or community agencies in the event of the relocation of residents, affecting 48 current residents. Findings include: Review of the residences' undated temporary relocation procedure policy read "The (residence) has agreements with the relocation sites indicated on the following pages." The following pages had blank spaces to insert the required information. The policy further read "The residence will establish a relationship with appropriate transportation companies," and "The residence has agreements with the following suitable transportation companies." There were no documented agreements with transportation companies. On 10/1/24 at 10:50 a.m., the administrator stated the residence had no written agreements with other facilities in the event of a relocation. She also stated the residence had no agreements with any transportation companies to assist with an emergency evacuation. The administrator later acknowledged their emergency preparedness plans were lacking.

Plan of correction · submitted by the facility

Self-Determination:Areas of concern cited in the recent 10/01/24 re-visit survey have been recognized and practices have been /and will be implemented to ensure the Lodge at Grand Junction will adhere to the following Plan of Correction (POC). Identification of Others:It is believed this deficient practice could have negatively impacted the Residents at the Lodge of Grand Junction. Administrator recognized these areas of concern. Corrective Action:Administrator and IDT, have reviewed the Emergency Preparedness Red Binder, kept at front desk, and multiple accessible areas of the facility. An updated, Red Binder will be drafted to ensure all areas of binder/policy are addressed. Including current listings of Resident names, location, emergency contact information, room number, and evacuation status. Facility diagram has been updated to better show room numbers making them legible, this diagram will also be kept in Red Binder for easy access. Concierge will continue to update Resident names and roster. Mapping will include, fire extinguisher locations, pull alarms. Resident council is educated on the Fire alarm and evacuation processes for/during each fire drill. and will continue quarterly. Staff are also educated monthly on Emergency Preparedness processes, will ensure education is provided again at all staff 10/31/24, A walk-through will be conducted to ensure instruction. Staff are familiar with our Walkie-Talkie communication system, and need to wear for emergency. Staff have been educated on Emergency systems and processes during All Staff meetings, and upon orientation by BSD.MOU/will be drafted with sister (Solstice) buildings as planned, this will also allow for transportation from one facility to the next. Both Solstice buildings will have adequate space. 10/31/24. This facility has adequate water, blankets, flashlights, food supplies, PPE to sustain itself independently. Administrator currently has a listing of call out protocol, notifications and areas of concentration for each Manager and staff on duty. The Lodge is also equipped with Fire rated Apartment doors, to ensure safety to shelter in place. Facility is equipped with a generator system for back-up power. Sustainability:IDT will review policies, and maintain Bed binders to ensure each employee will be competent in processes. 10/31/24. Administrator will bring forward current copies of Resident roster, over the next 90 days submitting through QMP process. The administrator will continue to monitor QMP quarterly to ensure compliance continues to be met. The Administrator and IDT will continue to draft processes for evacuation and conduct training. 10/31/24.

1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based upon record review and interview, the residence failed to ensure medication cart audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting 48 current residents. Findings include 1. ReferencesThe residence's 12/1/23 medication records policy read in part that medication records would be audited on a quarterly basis. On 10/1/24 at approximately 9:30 a.m., the controlled substance list was requested and not received during the onsite visit. On 10/1/24 at approximately 1:40 p.m., documentation of quarterly medication audits were reviewed, and there was no evidence that the administrator participated in the audit. 2. Interviews On 10/1/24 at approximately 1:40 p.m., the resident care coordinator stated she often completed medication cart audits; however, the administrator did not participate on a quarterly basis. On 10/1/24 at 4:45 p.m., the administrator stated she oversaw all aspects of the residence but felt quarterly medication audits did not need to be completed by the administrator in case of probable liability issues with medications. The administrator acknowledged that she, along with the QMAP supervisor, did not participate in medication audits on a quarterly basis.

Plan of correction · submitted by the facility

Self Determination:Areas of concern cited 10/1/24, The Administrator failed to follow Regulation as it pertains to Medication audits., Although Administrator does ensure audits are conducted monthly by the Pharmacy, and audited consistently by Lead QMAP’s, the Administrator failed to oversee audit, and signature sign off. Identification of Others:It is believed this deficient practice could have negatively impacted the Residents at the Lodge of Grand Junction. The Administrator and the RCC will conduct a quarter audit of medication cards and will document any discrepancies. The Administrator will sign off as well as the RCC will sign off on Medication audits quarterly and when conducted by Pharmacy and noted. RCC has been educated on the urgency to provide requested information to the Survey team when requested. Sustainability:The Administrator will bring forward monthly to QMP, and report any concerns, or Action Plans to further correct over the next 90 days and quarterly to ensure continued compliance.

10/1/2024Revisit: Licensure Complaint · ID VMS012No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 10/1/24 for all previous deficiencies cited on 6/30/22. The residence is in compliance with all regulations surveyed.

Plan of correction

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

Reportable Occurrences

6 records

3/6/2026Brain Injury · ID 2623W782003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/7/26, 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 prevent a future recurrence. The healthcare entity reported a brain injury of a client. Client (A) had a witnessed fall on 3/5/26 without complaints of pain, and then an unwitnessed fall on 3/6/26. Client (A) was found in a seated position on the floor with emesis on the floor. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. On 3/6/26 the client had a change in condition and was sent to the hospital. The client was diagnosed with a brain injury at the hospital, however was not a surgical candidate. The client passed away several days later at the hospital. Fall training was reviewed with staff regarding policies and procedures. 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 4/14/2026 · released to the public 4/21/2026.

2/18/2026Brain Injury · ID 2623W782002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 2/18/26, 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 prevent a future recurrence. The healthcare entity reported a brain injury of a client. The client had an unwitnessed fall with visible injuries. 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: increased safety checks, one-to-one from staff, escorts when walking and follow up appointments with their medical provider. 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 3/16/2026.

7/5/2024Neglect · ID 2423W782001Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/5/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported neglect of a client. During the course of the investigation the healthcare entity conducted interviews, searched for a plausible cause and ensured the client was safe. A staff member who was off duty found client (A) down the street. Staff neglected to check and ensure a door was not left unlatched and unsecured disarming the door alarm. Emergency exit signs were ordered, Staff were educated not to use the exit doors for daily use when carrying out tasks. Staff increase safety checks for the client. 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 4/8/2025 · released to the public 4/15/2025.

10/28/2023Misappropriation of Property · ID 2323W782006Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 10/28/23, a legal representative/family member of Resident A in her 90’s alleged a secondary family member had a history of exploiting and neglecting Resident A, and was concerned it was occurring again. The legal representative reported that the secondary family member was making attempts to revoke the legal representative’s power of attorney for Resident A. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, ombudsman and adult protective services. Staff were directed to be cautious of the actions of the secondary family member and to report should anyone attempt to have Resident A sign paperwork. During interviews, the legal representative stated he and an attorney for Resident A came to an agreement that Resident A could return to Grand Junction on the condition Resident A live in a facility and not with the secondary family member. Prior to this, Resident A had lived in Centennial in a facility, where her assets were protected by the attorney. Resident A was assessed for deficits in cognition and judgement. A recent mental status examination, completed on 10/30/23, revealed Resident A suffered from mild cognitive disorder. Currently, the secondary family member spent much of the day in the facility with Resident A. The legal representative stated he funded a credit card with a monthly allowance to pay the secondary family member for dog care, Resident A’s incidentals, and to take her out for shopping or dinners. The secondary family member did not permit the administrator to have a private conversation with Resident A. There were questions regarding a recent injury to Resident A’s ankle. Resident A had no recollection of the injury, although complained of pain. The secondary family member stated she had accelerated the resident’s wheelchair into a doorway, causing the ankle to be hit. The secondary family member had not reported this to the facility, but did have the ankle x-rayed which was negative for fracture. The secondary family member stated Resident A’s physician deemed her competent, which was discrepant from previous assessments. Subsequently, the administrator and adult protective services case manager met with Resident A privately, when the secondary family member was not in the facility. Resident A expressed she was being taken advantage of by the legal representative by giving him money and access to her accounts, and believed the secondary family member was taking good care of her. From the investigation, the facility concluded that there had been a pattern of misappropriate of property in the past, but did not substantiate the current allegations. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility 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 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 7/8/2024 · released to the public 7/15/2024.

8/12/2023Verbal Abuse · ID 2323W782004Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 8/14/23, resident (A) in her 80s was found by staff member (2) crying as she got on the elevator. She was hesitant at first but then stated she was talked to in a rude manner by staff (1). Resident (A) also stated staff (1)’s tone of voice and physical reactions were intimidating and she was fearful of retaliation if she said anything. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, Adult Protective Services, family/guardian and ombudsman. Staff (1) was suspended pending the investigation. Resident (A) stated if you were not liked by staff (1), you could not get things, but if staff (1) liked you they would make accommodations for those residents. Resident (A) was distraught and inconsolable for approximately 30 minutes. Three other residents stated, staff (1) can be rude and sweet at times. They stated staff (1) did have favorite residents. Server (3) stated, staff (1) would tell some residents a “solid no” when asking for things and others get what they want. Staff (1) denied the allegations and was not remorseful or apologetic. The facility investigation concluded the allegation was substantiated. Staff (1)’s actions caused resident (A) to be humiliated and fearful. To help prevent a recurrence, staff (1) resigned immediately and will not be eligible for rehire. Staff were provided an in-service regarding abuse. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility 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 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 7/30/2024 · released to the public 7/30/2024.

6/28/2023Misappropriation of Property · ID 2323W782003Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 6/28/23 a family member of a memory care resident (A) reported resident (A)’s wedding rings were missing. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, ombudsman and Adult Protective Services. The family member did not recall a time frame but stated they last saw the rings when resident (A) got her nails done sometime last week. The rings were reported to be loose fitting. The activities staff stated residents recently participated in planting flowers. Staff assisted with looking for the rings over several days. Staff were interviewed and no information was obtained to indicate an assailant or what might have happened. The facility was unable to determine what happened to the wedding rings. Staff were educated again on processes of reporting concerns and misappropriation of property. The family of resident (A) was advised regarding having valuables in the facility. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is reported to be accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for reporting and conducting an internal investigation of this occurrence event.

Publication

Sent to facility 4/8/2024 · released to the public 4/8/2024.