Inspection Reports for
Bear Creek Senior Living
1685 S 21ST ST, COLORADO SPRINGS, CO, 80904-4207
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
25% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide timely and proper written discharge notice to a resident and her representative, and failure to allow the resident to return to the facility after hospitalization.
Complaint Details
The complaint investigation found that the facility did not provide the required written discharge notice to Resident #1 and her representative, nor notify the state long-term care ombudsman. The facility also failed to allow Resident #1 to return after hospitalization due to medication refusal and safety concerns. The resident's representative was unaware of appeal rights and desired to appeal the discharge.
Findings
The facility failed to provide Resident #1 and her representative with a written discharge notice including appeal rights and failed to notify the state long-term care ombudsman. Additionally, the facility did not permit Resident #1 to return after hospitalization due to medication refusal and inability to meet her needs. The deficiencies were determined to cause minimal harm and affected a few residents.
Deficiencies (2)
Failed to provide a written discharge notice to Resident #1 and her representative including reason, effective date, location, appeal rights, and notification to the ombudsman.
Failed to permit Resident #1 to return to the facility after hospitalization on 1/10/25.
Report Facts
Residents reviewed: 3
Residents affected: 1
Medication refusal date: 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Resident #1's medication refusal and hospitalization |
| Director of Nursing | DON | Interviewed about decision not to readmit Resident #1 |
| Assistant Director of Nursing | ADON | Provided facility policy and interviewed about discharge notice and readmission |
| Nursing Home Administrator | NHA | Interviewed about decision to not permit Resident #1's return |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 30, 2025
Visit Reason
The inspection was conducted due to a complaint regarding the facility's failure to provide timely written discharge notice and to permit a resident to return to the facility after hospitalization.
Complaint Details
The complaint investigation found substantiated failures related to discharge notice and readmission rights for Resident #1. The resident and representative did not receive written discharge notice or appeal information, and the resident was not permitted to return after hospitalization due to medication refusal.
Findings
The facility failed to provide Resident #1 and her representative with a written discharge notice including appeal rights at least 30 days prior to discharge. The facility also failed to send a copy of the discharge notice to the state long-term care ombudsman and did not permit Resident #1 to return to the facility after hospitalization due to medication refusal.
Deficiencies (2)
F 0623: The facility failed to provide Resident #1 and her representative a written discharge notice including the reason, effective date, location, appeal rights, and notification to the ombudsman at least 30 days before discharge.
F 0626: The facility failed to permit Resident #1 to return to the nursing home after hospitalization on 1/10/25 due to medication refusal and inability to meet resident needs.
Report Facts
Residents reviewed: 3
Residents affected: 1
BIMS score: 15
Hospitalization dates: Resident #1 hospitalizations on 8/15/24, 11/20/24, 12/24/24, and discharge on 1/10/25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding Resident #1 medication refusal and hospitalization |
| Director of Nursing | DON | Interviewed regarding decision not to readmit Resident #1 |
| Assistant Director of Nursing | ADON | Provided facility policy and interviewed regarding discharge notice and readmission |
| Nursing Home Administrator | NHA | Interviewed regarding IDT decision on Resident #1 readmission |
Inspection Report
Routine
Deficiencies: 4
Date: May 6, 2024
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of care, medication administration, infection prevention and control, and vaccination policies at Bear Creek Senior Living.
Findings
The facility failed to clarify a physician's order for oxygen therapy for one resident, had multiple medication administration errors affecting three residents, failed to maintain an effective Legionella water management program, and did not offer COVID-19 and pneumococcal vaccines to one resident as required.
Deficiencies (4)
Failed to ensure physician's order for oxygen use was clarified for Resident #17.
Failed to ensure residents were free from significant medication errors for Residents #18, #6, and #188.
Failed to maintain an infection control program including monitoring water for Legionella growth and offering COVID-19 vaccine to Resident #12.
Failed to develop and implement policies and procedures to ensure Resident #12 was offered pneumococcal vaccine.
Report Facts
Residents reviewed for oxygen therapy: 23
Residents reviewed for medication errors: 23
Residents reviewed for vaccinations: 23
Missed doses of Amoxicillin: 7
Missed doses of Umeclidinium/Vilanterol: 9
Missed doses of Fluticasone nasal spray: 11
Missed doses of Hydrocodone-Acetaminophen: 10
Water temperature readings: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding oxygen therapy order clarification for Resident #17 |
| RN #2 | Registered Nurse | Interviewed regarding medication ordering and follow-up processes |
| DON | Director of Nursing | Interviewed regarding oxygen therapy, medication errors, water management, and vaccination policies |
| ADON | Assistant Director of Nursing | Interviewed regarding vaccination tracking and documentation |
| MTD | Maintenance Director | Interviewed regarding water temperature monitoring and Legionella testing |
Inspection Report
Annual Inspection
Deficiencies: 4
Date: May 6, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with healthcare regulations and standards at Bear Creek Senior Living.
Findings
The facility had deficiencies related to respiratory care, medication administration errors, infection prevention and control, and vaccination procedures. The facility failed to clarify oxygen orders, ensure timely medication administration, maintain a water management program for Legionella, and properly offer COVID-19 and pneumococcal vaccines to residents.
Deficiencies (4)
F 0695: The facility failed to ensure the physician's order for oxygen use was clarified to specify when Resident #17 should use supplemental oxygen.
F 0760: The facility failed to ensure residents were free from significant medication errors, including missed doses of antibiotics, inhalers, nasal sprays, and pain medications for Residents #18, #6, and #188.
F 0880: The facility failed to maintain an infection control program by not adequately monitoring water temperatures to prevent Legionella growth and not offering the COVID-19 vaccine to Resident #12.
F 0883: The facility failed to develop and implement policies and procedures to ensure Resident #12 was offered the pneumococcal vaccine upon admission.
Report Facts
Residents reviewed for oxygen therapy: 23
Residents reviewed for medication errors: 23
Missed antibiotic doses: 7
Missed inhaler doses: 9
Missed nasal spray doses: 11
Missed pain medication doses: 7
Water temperature readings: 5
Inspection Report
Annual Inspection
Deficiencies: 4
Date: Jan 26, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory standards for nursing home care, including treatment and care, accident prevention, enteral feeding safety, and medication storage.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate treatment and care for a resident with high blood pressure, inadequate supervision and fall prevention leading to multiple falls with injury, unsafe enteral feeding practices including improper positioning and unlabeled supplies, and failure to discard expired medical supplies.
Deficiencies (4)
Failed to intervene and notify physician for high blood pressure and unavailable medications for Resident #27.
Failed to provide adequate supervision and assistance to prevent falls for Resident #82, resulting in multiple falls and injury.
Failed to safely monitor and administer enteral nutrition for Resident #12, including unlabeled feeding formula and improper resident positioning.
Failed to ensure drugs and biologicals were labeled and stored properly; expired medical supplies were found in medication room.
Report Facts
Sample residents reviewed: 14
Resident #27 blood pressure readings: 181
Resident #82 fall incidents: 3
Fall risk score: 22
Enteral feeding formula hang time: 18
Expired medical supplies: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding medication administration and expired supplies |
| DON | Director of Nursing | Interviewed regarding facility policies and expectations for medication notification, fall prevention, and enteral feeding |
| RN #1 | Registered Nurse | Interviewed about medication administration and expired supplies |
| CNA #1 | Certified Nurse Aide | Interviewed about resident supervision and fall risk information |
| CNA #2 | Certified Nurse Aide | Interviewed about communication and supervision of Resident #82 |
| CNA #3 | Certified Nurse Aide | Interviewed about resident care plan access and supervision frequency |
| LPN #1 | Licensed Practical Nurse | Interviewed about Resident #82 fall incident and enteral feeding observations |
Inspection Report
Complaint Investigation
Deficiencies: 4
Date: Jan 26, 2023
Visit Reason
The inspection was conducted to investigate complaints related to inadequate treatment and care, fall prevention failures, improper enteral feeding practices, and medication/supply storage issues at Bear Creek Senior Living.
Complaint Details
The complaint investigation substantiated failures in treatment and care for high blood pressure, fall prevention and supervision, enteral feeding safety, and medication/supply storage practices.
Findings
The facility failed to provide appropriate treatment and care for a resident with high blood pressure, failed to prevent falls resulting in injury for another resident, failed to safely monitor and administer enteral nutrition for a resident, and failed to properly label and discard expired medical supplies.
Deficiencies (4)
F 0684: The facility failed to intervene or notify the physician when a resident had high blood pressure and prescribed medications were unavailable, resulting in lack of appropriate treatment.
F 0689: The facility failed to provide adequate supervision and interventions to prevent falls for a resident with severe cognitive impairment, resulting in three falls within three days and one major injury requiring hospitalization.
F 0693: The facility failed to safely monitor and administer enteral nutrition by not labeling feeding formula and supplies properly and not ensuring the resident was positioned with head elevated during feeding.
F 0761: The facility failed to discard expired medical supplies in the medication and supply storage room, risking use of expired items for resident care.
Report Facts
Sample residents reviewed: 14
Resident #27 sample size: 1
Resident #82 sample size: 1
Resident #12 sample size: 1
Expired medical supplies: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding medication administration and expired supplies |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding enteral feeding observations and resident care |
| Director of Nursing | Director of Nursing | Interviewed regarding facility policies, resident care expectations, and staff education |
| CNA #1 | Certified Nurse Aide | Interviewed regarding falls prevention and resident supervision |
| CNA #2 | Certified Nurse Aide | Interviewed regarding communication and falls prevention |
| CNA #3 | Certified Nurse Aide | Interviewed regarding resident care plan access and falls prevention |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 4, 2021
Visit Reason
The inspection was conducted due to complaints regarding failure to provide necessary assistance with activities of daily living (ADLs), inadequate supervision to prevent accidents, and failure to maintain an infection prevention and control program.
Complaint Details
The complaint investigation found substantiated failures in providing necessary ADL assistance, supervision to prevent falls, and infection control measures. Specific incidents included residents not receiving showers as scheduled, a resident falling from bed during incontinence care resulting in fractures, and staff not adhering to PPE protocols or screening procedures.
Findings
The facility failed to ensure residents received scheduled showers and personal hygiene assistance, failed to provide adequate supervision preventing falls resulting in injuries, and failed to maintain proper infection control practices including PPE use and visitor screening.
Deficiencies (3)
Failure to provide scheduled showers and personal hygiene assistance to residents #83, #79, and #77.
Failure to provide adequate supervision and accident hazard prevention resulting in falls and injuries to residents #84 and #2.
Failure to provide and implement an infection prevention and control program including proper PPE use and visitor/staff screening.
Report Facts
Sample residents reviewed: 21
Residents affected: 3
Residents affected: 2
Fall risk score: 16
Fall risk score: 18
Dates of missed bathing for Resident #83: 7
Days without bath/shower for Resident #77: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in fall incident involving Resident #84 and related findings |
| Director of Nursing | Director of Nursing | Interviewed regarding deficiencies in ADL assistance, fall investigations, and infection control |
| Certified Nursing Aide #1 | Certified Nursing Aide | Mentioned in infection control deficiency for not using PPE properly |
| Certified Nursing Aide #2 | Certified Nursing Aide | Mentioned in infection control deficiency for improper glove use and hand hygiene |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 4, 2021
Visit Reason
The inspection was conducted due to complaints regarding failure to provide necessary care for residents unable to perform activities of daily living, inadequate supervision to prevent accidents, and failure to maintain infection control protocols.
Complaint Details
The complaint investigation substantiated failures in providing scheduled personal care, preventing resident falls with injuries, and maintaining infection control protocols including PPE use and visitor screening.
Findings
The facility failed to ensure residents received scheduled showers and personal hygiene care, failed to provide adequate supervision to prevent falls resulting in injuries, and failed to maintain proper infection prevention and control measures including PPE use and visitor screening.
Deficiencies (3)
F 0677: The facility failed to provide showers and personal hygiene care as scheduled for three residents (#83, #79, and #77), despite care plans indicating extensive assistance was needed.
F 0689: The facility failed to provide adequate supervision and a safe environment to prevent falls for two residents (#84 and #2), resulting in a closed fracture and refractured rib for Resident #84 and multiple falls for Resident #2 without proper investigation or communication.
F 0880: The facility failed to maintain an infection control program by not ensuring staff wore appropriate PPE, performed hand hygiene between resident cares, and screened visitors and vendors for COVID-19 symptoms.
Report Facts
Residents affected: 3
Residents affected: 2
Fall risk score: 16
Fall risk score: 18
BIMS score: 9
BIMS score: 11
BIMS score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Named in fall incident involving Resident #84 |
| Director of Nursing | Director of Nursing | Interviewed regarding failures in fall investigations and infection control |
| Certified Nursing Aide #1 | Certified Nursing Aide | Observed not using appropriate PPE and unaware of isolation precautions |
| Certified Nursing Aide #2 | Certified Nursing Aide | Observed not changing gloves or performing hand hygiene during resident care |
Viewing
Loading inspection reports...
