Inspection Reports for
Forest Ridge Health and Rehab LLC
16006 W US HIGHWAY 24, WOODLAND PARK, CO, 80863-8760
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
3.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
27% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 8, 2025
Visit Reason
The inspection was conducted to investigate allegations of resident-to-resident physical abuse incidents occurring on 8/9/25 and 8/16/25 involving multiple residents.
Complaint Details
The complaint investigation substantiated abuse occurred between residents on 8/9/25 and 8/16/25. The facility investigations documented physical altercations involving Resident #1, Resident #2, and Resident #3, with injuries and behavioral concerns noted. Staff interviews confirmed the incidents and described interventions.
Findings
The facility failed to protect three residents from physical abuse by other residents on multiple occasions. Investigations confirmed abuse occurred between Resident #1, Resident #2, and Resident #3, with injuries documented and interventions attempted but ultimately ineffective.
Deficiencies (1)
F 0600: The facility failed to protect residents from all types of abuse including physical abuse. Specifically, three residents were involved in multiple physical altercations on 8/9/25 and 8/16/25, resulting in injuries and requiring staff intervention.
Report Facts
Residents involved in abuse incidents: 3
Dates of incidents: 8/9/25 and 8/16/25
BIMS scores: Resident #1 scored 3/15, Resident #2 scored 10/15, Resident #3 scored 2/15 on cognitive assessments
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse (RN) #1 | Witnessed the 8/9/25 physical abuse incident between Resident #1 and Resident #2 | |
| Social Services Director (SSD) | Conducted interviews with residents and staff regarding abuse incidents | |
| Assistant Director of Nursing (ADON) | Reviewed video surveillance and was notified of incidents | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding resident behavior and unit environment | |
| Certified Nurse Aide (CNA) #1 | Interviewed about resident behaviors and unit staffing | |
| Certified Nurse Aide (CNA) #2 | Interviewed about resident behaviors and unit staffing | |
| Registered Nurse (RN) #2 | Witnessed the 8/16/25 physical abuse incident between Resident #1 and Resident #3 | |
| Certified Nurse Aide (CNA) #3 | Witnessed the 8/16/25 physical abuse incident between Resident #1 and Resident #3 |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 23, 2024
Visit Reason
The inspection was conducted to investigate complaints related to falls and inadequate supervision at Forest Ridge Health and Rehab LLC.
Complaint Details
The investigation focused on falls experienced by residents #68 and #70, with findings that the facility did not implement timely interventions or identify root causes for these falls. The complaint was substantiated with evidence of inadequate supervision and delayed care plan updates.
Findings
The facility failed to ensure adequate supervision and timely interventions to prevent falls for residents #68 and #70. The care plans were not updated promptly after falls, and root causes were not identified or addressed effectively.
Deficiencies (3)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent falls for residents #68 and #70.
Resident #70 had multiple falls between 3/6/24 and 5/16/24 with delayed or missing updates to the fall care plan and no documented root cause analysis after falls.
Resident #68 had falls on 4/13/24 and 5/16/24 with delayed implementation of interventions and no root cause analysis or timely updates to the fall care plan.
Report Facts
Number of falls for Resident #70: 6
Number of falls for Resident #68: 2
Fall risk assessment score for Resident #68: 65
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Interviewed regarding Resident #70's falls and supervision. |
| RN #4 | Registered Nurse | Interviewed regarding Resident #70's falls and behavior. |
| CNA #7 | Certified Nurse Aide | Interviewed about Resident #70's fall frequency and supervision. |
| CNA #8 | Certified Nurse Aide | Interviewed about Resident #70's supervision and falls. |
| CNA #6 | Certified Nurse Aide | Interviewed about Resident #68's fall risk and supervision. |
| RN #2 | Registered Nurse | Interviewed about Resident #68's fall risk and supervision. |
| DON | Director of Nursing | Interviewed regarding facility fall policies, interventions, and oversight. |
Inspection Report
Routine
Deficiencies: 6
Date: May 23, 2024
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident care, medication management, infection control, and safety.
Findings
The facility was found deficient in multiple areas including fall prevention interventions, nutritional care, bed rail use and documentation, medication storage and labeling, food safety practices, wound care technique, and infection control related to Legionella water management.
Deficiencies (6)
F 0689: The facility failed to implement timely and effective fall prevention interventions and update care plans after each fall for residents #68 and #70, and did not identify root causes of falls.
F 0692: The facility failed to provide adequate nutritional care for Resident #68, resulting in severe weight loss due to lack of timely and effective nutritional interventions and failure to follow dietary recommendations.
F 0700: The facility failed to assess, obtain consent, order, and conduct quarterly evaluations for bed rail use for eight residents, and did not perform routine maintenance inspections of bed rails.
F 0761: The facility failed to ensure proper medication storage and labeling, including undated and expired Tuberculin PPD and storing medications with food and beverages in refrigerators.
F 0812: The facility failed to monitor and document refrigerator and freezer temperatures consistently and lacked a system to monitor dishwasher internal temperatures to ensure proper sanitation.
F 0880: The facility failed to maintain infection control during wound care for Resident #56 by not establishing a clean field and not performing hand hygiene or glove changes appropriately, and lacked an active Legionella water management program.
Report Facts
Weight loss: 13.8
Weight loss: 12.6
Fall incidents: 6
Temperature log missing entries: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in wound care clean technique deficiency for Resident #56. |
| RN #1 | Registered Nurse | Observed medication refrigerator and interviewed about medication storage. |
| DON | Director of Nursing | Interviewed regarding fall prevention, bed rail use, and wound care deficiencies. |
| ADON | Assistant Director of Nursing | Interviewed regarding nutritional care and medication storage. |
| DM | Dietary Manager | Interviewed regarding food safety and temperature monitoring. |
| DA #1 | Dietary Aide | Interviewed regarding dishwasher operation and temperature logs. |
| IP | Infection Preventionist | Interviewed regarding Legionella water management program. |
| ESD | Environmental Services Director | Interviewed regarding Legionella water management program. |
| NHA | Nursing Home Administrator | Interviewed regarding Legionella water management program and medication storage. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Mar 10, 2020
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide appropriate diabetic management, respiratory care, infection prevention and control, and medication administration practices at the nursing home.
Complaint Details
The investigation was complaint-driven, focusing on allegations of inadequate diabetic care, respiratory therapy, infection control, and medication administration. The complaint was substantiated with findings of noncompliance in these areas.
Findings
The facility failed to follow physician orders for diabetic management and oxygen therapy for multiple residents, resulting in potential harm. Infection prevention practices were inadequate, including poor hand hygiene and failure to assist residents with handwashing. Medication administration procedures were not properly followed, including improper handling of refused medications.
Deficiencies (3)
F 0684: The facility failed to ensure physician orders related to diabetic management were followed for Resident #27, resulting in untreated low blood glucose levels on multiple occasions.
F 0695: The facility failed to provide safe and appropriate respiratory care by not ensuring continuous oxygen therapy as ordered for 11 residents, including Resident #27, resulting in residents being without oxygen and experiencing distress.
F 0880: The facility failed to implement effective infection prevention and control practices, including inadequate hand hygiene by staff and failure to assist residents with handwashing, increasing risk of infection spread.
Report Facts
Blood glucose readings below or equal to 80 mg/dL: 20
Residents requiring respiratory care: 32
Residents affected by oxygen therapy deficiency: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #5 | Registered Nurse | Interviewed regarding Resident #27's diabetic management and oxygen therapy. |
| Director of Nursing | Director of Nursing | Interviewed regarding expectations for following physician orders and oxygen therapy monitoring. |
| RN #4 | Registered Nurse | Interviewed about oxygen tank monitoring and medication administration practices. |
| CNA #6 | Certified Nurse Aide | Interviewed about oxygen tank refilling and training. |
| CNA #8 | Certified Nurse Aide | Interviewed about oxygen tank monitoring and training. |
| RN #1 | Registered Nurse | Interviewed about medication administration and handling of refused medications. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 18, 2019
Visit Reason
The inspection was conducted to investigate complaints related to failure to provide care by qualified persons after resident falls and failure to investigate bruises of unknown origin.
Complaint Details
The investigation was triggered by complaints regarding failure to provide proper nursing assessments after falls and failure to investigate bruises on residents. The complaints were substantiated with findings of minimal harm and few residents affected.
Findings
The facility failed to ensure a registered nurse assessed a resident after a fall before moving her, resulting in a fractured femur. The facility also failed to properly assess and monitor bruises of unknown origin on another resident, with inconsistent documentation and lack of full skin assessments.
Deficiencies (2)
F0659: The facility failed to provide care by qualified persons for one resident by not ensuring a registered nurse assessed the resident after a fall prior to moving her, resulting in a fractured femur.
F0689: The facility failed to ensure the nursing home area was free from accident hazards and did not adequately investigate a bruise of unknown origin for one resident, with inconsistent documentation and incomplete skin assessments.
Report Facts
Residents reviewed for falls: 26
Residents affected: 2
Fall date: Jan 11, 2019
Fall date: Mar 4, 2019
Fall date: Mar 9, 2019
Morse Fall Scale score: 90
Morse Fall Scale score: 80
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Assessed Resident #44 after fall and assisted in transferring her |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding assessment procedures and approved LPN assessments |
| RN #3 | Registered Nurse | Documented fall notes and skin observations for Resident #16 |
| LPN #1 | Licensed Practical Nurse | Documented bruise observations for Resident #16 |
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