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Assisted LivingMedicaid Investigative

Retreat at Harbor Cove

Reviewer concerns include poor food quality and inadequate nutrition (mentioned by 5 reviewers) — investigate before committing.

2835 Patterson Rd, Grand Junction, CO 8150664 bedsLicensed & Active
Source: CO CDPHE — view official record
Google rating
1.8/5

based on 14 Google reviews

5
4
3
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1
Retreat at Harbor Cove Assisted Living in Grand Junction, CO — Street View
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What this means for your family

While one recent reviewer had a positive experience, the overwhelming majority of feedback highlights severe issues with food quality, medication safety, and staff neglect. We strongly advise families to conduct unannounced visits and speak directly with current residents and their families to verify the quality of care before committing.

Google Reviews

Google Reviews

14 reviews on Google
The Retreat at Harbor Cove receives overwhelmingly negative feedback, with multiple reviewers citing poor food quality, lack of staff responsiveness, and cleanliness issues. While one recent reviewer reported a positive experience with staff treating their father with respect, the majority of reports describe a pattern of neglect, poor communication, and serious safety concerns.

Quality Themes

Tap a score for details
Food0.0Staff2.0Clean1.0ActivitiesN/AMeds0.0MemoryN/AComms1.0Value0.0

Strengths

  • Recent reports of respectful staff interactions
  • Assistance with activities of daily living (ADLs)

Concerns

  • Poor food quality and inadequate nutrition (mentioned by 5 reviewers)
  • Negligent staff behavior and lack of supervision (mentioned by 4 reviewers)
  • Poor communication and lack of management accountability (mentioned by 3 reviewers)

Rating Trends

Tap a year to see what changed

234'13(2)'16(2)'21(2)'23(2)'26(8)

Distribution · 28 analyzed

5
2
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3
0
2
2
1
20

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1Could you walk us through the current process for menu planning and how you ensure residents are receiving balanced, high-quality nutrition?
  • 2What specific steps has management taken recently to improve communication protocols between the staff and family members?
  • 3How does the facility ensure consistent supervision and engagement for residents throughout the day and evening hours?
  • 4Can you describe your current system for medication management and how you track that each resident receives their correct dosage on time?
  • 5What is your daily cleaning schedule for resident rooms and common areas, and how is the quality of that maintenance monitored?
  • 6Could you share how your staff is trained to handle medical emergencies and what the protocol is for notifying families during an urgent situation?

Personalized based on this facility's data


Key Review Excerpts

We only moved my dad in just over a week ago, truthfully I was a little worried with the reviews on here but they have done nothing but treat him with love and respect!

Long-term resident's family · 2024★★★★

The staff continued to come in without masks or gloves. She ended up with covid. The staff continued to come in without protection when she was an active covid case.

Long-term resident's family · 2022☆☆☆☆

The Stuff is Lazy and Rude the food is bad they gave me someone else Medication which I had to return it back to the facility and they act like it was no big deal

Resident · 2024☆☆☆☆
Source: 14 Google reviews

State Inspection History

State Inspections

Source: CO Dept. of Public Health & Environment

10total
3deficiencies
Jan 21, 2025Complaint
CleanReport

No deficiencies found during this inspection.

Jan 21, 2025Complaint
CleanReport

No deficiencies found during this inspection.

Jan 21, 2025Complaint
CleanReport

No deficiencies found during this inspection.

Dec 10, 2024Complaint
N/A0000 & 1568

A relicensure and complaint revisit was completed on 12/10/24 for all previous deficiencies cited on 1/23/24. A deficiency was cited.The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24. Based on observation, record review, and interview the residence failed to comply with practitioner orders associated with medication administration affecting two of seven sample residents (#21 and #31).This deficiency was cited previously during a complaint revisit on 1/23/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewResident #21 was admitted to the residence on 2/12/22 with diagnoses of hypothyroidism and type 2 diabetes mellitus.A practitioner' s order, dated 11/11/24, directed the residence to administer tramadol 25 mg at bedtime and allow an extra 25 mg as needed for pain. However, the December 2024 medication administration record (MAR) read the residence failed to administer the medication from 12/4-12/8/24 due to the medication being out of stock, for a total of five missed doses.A practitioner' s order, dated 11/11/24, directed the residence to administer levothyroxine sodium hcl 137 MCG daily. However, the December 2024 MAR read the residence failed to administer the medication from 12/8- 12/10/24 for a total of three missed doses.A practitioner' s order, dated 11/11/24, directed the residence to administer loratadine 10 mg daily. However, the December 2024 MAR read the residence failed to administer the medication from 12/7- 12/8/24 and 12/10/24 for a total of three missed doses. Evidence revealed similar deficient practice with Resident #31.2. ObservationOn 12/10/24 at 7:35 a.m., Staff #29 failed to administer levothyroxine sodium hcl 137 MCG and 10 loratadine 10 mg to Resident #21 due to the medications being out of stock.3. InterviewsOn 12/10/24 at 7:35 a.m., Staff #29 reported the residence did not have Resident #21' s levothyroxine sodium and loratadine in stock. Staff #29 reported the qualified medication administration personnel (QMAP) reviewed medications and re-ordered them twice a week and were unsure why the residence did not have th..

Dec 10, 2024Complaint
CleanReport

No deficiencies found during this inspection.

Dec 10, 2024Complaint
CleanReport

No deficiencies found during this inspection.

Dec 10, 2024Complaint
CleanReport

No deficiencies found during this inspection.

Dec 10, 2024Complaint
N/A0000 & 0920

A recertification and complaint revisit was completed on 12/10/24 for all previous deficiencies cited on 1/23/24. A deficiency was cited. The regulations governing Home and Community-Based Services were revised, and the new regulations were implemented on 3/16/24. Based on observation, record review, and interview the facility (residence) failed to provide sufficient support to members in the use of prescription and nonprescription medication, affecting two of seven sample members (residents) (#21 and #31).This deficiency was cited previously during a recertification survey and complaint investigation on 1/23/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement.Findings include:1. Record ReviewResident #21 was admitted to the residence on 2/12/22 with diagnoses of hypothyroidism and type 2 diabetes mellitus.A practitioner' s order, dated 11/11/24, directed the residence to administer tramadol 25mg at bedtime and allow an extra 25mg as needed for pain. However, the December 2024 medication administration record (MAR) read the residence failed to administer the medication from 12/4-12/8/24 due to the medication being out of stock, for a total of five missed doses.A practitioner' s order, dated 11/11/24, directed the residence to administer levothyroxine sodium hcl 137 MCG daily. However, the December 2024 MAR read the residence failed to administer the medication from 12/8- 12/10/24 for a total of three missed doses.A practitioner' s order, dated 11/11/24, directed the residence to administerloratadine 10 mg daily. However, the December 2024 MAR read the residence failed to administer the medication from 12/7- 12/8/24 and 12/10/24 for a total of three missed doses.Evidence revealed similar deficient practice with Resident #31.2. ObservationOn 12/10/24 at 7:35 a.m., Staff #29 failed to administer levothyroxine sodium hcl 137 MCG and 10 loratadine 10 mg to Resident #21 due to the medications being out of stock.3. InterviewsOn 12/10/24 at 7:35 a.m., Staff #29 reported the residence did not have Resident #21' s levothyroxine sodium and loratadine in stock. Staff #29 reported the qualified medication administration personnel (QMAP) reviewe..

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References & Resources

EveryPlace is a research directory. Facility information is compiled from public sources — Medicare.gov, state licensing portals, Google Places, and publicly available street-level imagery. Listings do not constitute endorsement, recommendation, or advertisement, and we do not accept payment for placement. Families should verify all details directly with the facility and the original sources linked above before making any care decisions. See our Research Policy for our editorial standards, correction process, and image-removal policy.

Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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