DURANGO, CO- Resident given 4 times the ordered dose of liquid opioid, ultimately leading to resident’s decline and death. Director of Nursing states “was unaware, until it was brought to her attention during the survey process”.

STERLING, CO-Facility failed to put in place interventions to prevent multiple falls for multiple residents.

COLORADO SPRING, CO- Resident suffer femur fracture due to neglect of transfer order. Facility substantiated neglect claim but did not report to state until 8 days later.

SEATTLE, WA-Director of Nursing showed the facility did not meet the required number of staff needed to meet the needs of residents. Staff admits to no training or education, not knowing or where to locate residents care plan.

COLORADO SPRINGS, CO- Resident passes after “severe-protein calorie malnutrition”. ADON serving as wound nurse, admits “not had any training in wound care” as resident develops pressure ulcer.