Inspection Reports for
Life Care Center of Stonegate
15720 GARDEN PLAZA DR, PARKER, CO, 80134-9103
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
5.3 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
2% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 2
Date: Aug 25, 2025
Visit Reason
The inspection was conducted to assess the facility's compliance with care planning and fall prevention requirements following incidents involving falls with major injuries to residents.
Findings
The facility failed to develop and implement baseline care plans within 48 hours of admission that included necessary fall prevention and fracture care interventions for residents at high risk of falling. Two residents sustained falls resulting in major injuries, including fractures and an open skull fracture, due to inadequate supervision and incomplete care plans.
Deficiencies (2)
F 0655: The facility failed to create and implement a baseline care plan within 48 hours of admission that included fall prevention and fracture care interventions for residents at high risk of falling.
F 0689: The facility failed to ensure adequate supervision and accident hazard prevention, resulting in falls with major injuries for two residents, including fractures and an open skull fracture.
Report Facts
Fall risk score: 16
Fall risk score: 22
Number of residents reviewed: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding fall risk assessments and care plan procedures | |
| Certified Nurse Aide (CNA) #1 | Interviewed about knowledge of residents' special care needs and fall risk | |
| Director of Nursing (DON) | Interviewed about facility policies, fall risk assessments, and care plan implementation |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 3, 2024
Visit Reason
Routine inspection of Life Care Center of Stonegate to assess compliance with regulatory standards including resident care, medication administration, infection control, and staff training.
Findings
The facility failed to honor resident bathing preferences for multiple residents, ensure appropriate skin and wound care, complete dialysis communication forms accurately, prevent a significant medication error, maintain infection control practices including hand hygiene and PPE use, and provide effective orientation and training for agency staff.
Deficiencies (7)
F 0561: The facility failed to honor bathing preferences for four residents, resulting in missed showers and lack of documentation of refusals.
F 0684: The facility failed to ensure residents #181 and #177 received skin care as ordered and Resident #240's provider was not timely notified of delayed antibiotics or monitored vital signs during condition changes.
F 0686: The facility failed to provide timely and accurate pressure ulcer care and prevention for eight residents, including delayed wound care initiation and incomplete skin assessments.
F 0698: The facility failed to consistently complete pre- and post-dialysis assessments and communication forms for Resident #23.
F 0760: The facility failed to prevent a significant medication error when Resident #287 was given four times the prescribed dose of carvedilol, resulting in hypotension and hospital transfer.
F 0880: The facility failed to maintain infection control practices including hand hygiene during wound care, proper use of enhanced barrier precautions, sanitary handling of suction canisters, and cleaning of glucometers and vital sign machines.
F 0940: The facility failed to provide effective orientation and training for agency nursing staff, including incomplete orientation packets and skills checklists.
Report Facts
Medication overdose dose: 25
Blood pressure readings: 73
Resident sample size: 35
Residents affected by bathing deficiency: 4
Residents affected by skin care deficiency: 8
Residents affected by medication error: 1
Staff educated on admission orders: 52
Staff educated on double checking blood pressures: 112
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #2 | Licensed Practical Nurse | Entered incorrect carvedilol dose into EMR leading to medication overdose for Resident #287. |
| LPN #3 | Licensed Practical Nurse | Failed to catch incorrect carvedilol dose entered by LPN #2 for Resident #287. |
| LPN #1 | Licensed Practical Nurse | Administered incorrect carvedilol dose to Resident #287 and took vital signs. |
| DON | Director of Nursing | Provided interviews on medication error, infection control, and staff orientation. |
| DDCS | Divisional Director of Clinical Services | Provided interviews on medication error, infection control, and staff orientation. |
| IP | Infection Preventionist | Observed and interviewed regarding hand hygiene and PPE use during wound care. |
| CNA #1 | Certified Nurse Aide | Observed transferring resident without appropriate PPE. |
| CNA #3 | Certified Nurse Aide | Observed removing PPE improperly and not wearing PPE during wound care. |
| SC | Staffing Coordinator | Interviewed regarding agency staff orientation process. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 13, 2023
Visit Reason
The inspection was conducted due to complaints regarding cold shower temperatures and call light response times from residents and their representatives.
Complaint Details
The investigation was complaint-related, focusing on grievances from residents #1, #2, and #6 about cold shower temperatures and call light response times. The complaints were substantiated by interviews, observations, and record reviews.
Findings
The facility failed to provide prompt efforts to resolve grievances related to cold shower temperatures and call light response times for multiple residents. Observations confirmed shower temperatures were too cool, and there was no documentation of grievance follow-up or call light audits.
Deficiencies (1)
F 0585: The facility failed to address, resolve, document, and follow up on grievances for residents regarding cold shower temperatures and call light response times. The facility did not provide the requested grievance policy and lacked documentation of call light audits and shower temperature checks.
Report Facts
Shower temperature: 92.5
Shower temperature: 102.9
Call light wait time: 90
Call light wait time: 30
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Apr 13, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including failure to honor resident preferences, inadequate activity programming, unsafe water temperatures, improper resident transfers, incomplete nursing competencies, unnecessary medications, improper medication storage, and inadequate infection prevention and control practices.
Deficiencies (8)
F 0561: The facility failed to honor resident preferences for bathing and implement care based on self-determined preferences for two residents.
F 0679: The facility failed to provide activities that meet the interests and choices of residents for three of four sample residents.
F 0689: The facility failed to maintain safe water temperatures and ensure resident transfers were performed according to care plans, resulting in potential harm.
F 0726: The facility failed to ensure nursing staff completed required competencies prior to providing skilled services for three nurses reviewed.
F 0757: The facility failed to ensure one resident's drug regimen was free from unnecessary drugs and that pharmacy recommendations were followed.
F 0761: The facility failed to ensure medication storage met professional standards including double locking controlled substances and securing medication carts.
F 0880: The facility failed to maintain an infection control program including proper housekeeping hygiene, disinfecting shared equipment, wound care infection control, and hand hygiene between residents.
F 0943: The facility failed to provide required abuse identification, prevention, reporting, and dementia management training to some nursing and CNA staff.
Report Facts
Facility census: 56
Residents needing assistance with transfers: 54
Residents needing assistance with bathing: 53
Residents needing assistance with dressing: 54
Residents needing assistance with toileting: 54
Residents needing assistance with eating: 49
Pharmacy recommendations for omeprazole dose reduction: 40
Water temperature: 136.3
Water temperature: 138.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed performing wound care with improper infection control practices |
| CNA #1 | Certified Nurse Aide | Interviewed regarding bathing preferences and observed not disinfecting vitals equipment between residents |
| HSKP #1 | Housekeeper | Observed not following proper cleaning and disinfecting procedures and hand hygiene |
| DON | Director of Nursing | Interviewed regarding nursing competencies, medication storage, and pharmacy recommendations |
| SDC | Staff Development Coordinator | Interviewed regarding staff training and education |
| IP | Infection Preventionist | Interviewed regarding infection control program and housekeeping oversight |
| MTD | Maintenance Director | Interviewed regarding water temperature issues and housekeeping training |
| HS | Housekeeping Supervisor | Interviewed regarding housekeeping procedures and training |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Jan 6, 2022
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to resident assessments and care.
Findings
The facility failed to ensure accurate minimum data set (MDS) assessments for three residents, specifically in cognitive, mood, behavior, functional status, and health condition areas. The assessments lacked completion of required sections and did not reflect an accurate picture of the residents' status during the observation period.
Deficiencies (3)
F0641: The facility failed to ensure Resident #4's cognitive patterns, mood, and behavior were accurately assessed, with sections C, D, and E of the MDS not completed.
F0641: The facility failed to ensure Resident #7's health conditions were accurately assessed, with the pain assessment interview not completed in multiple MDS assessments.
F0641: The facility failed to ensure Resident #25's functional status and health conditions were accurately assessed, with incomplete sections G and J in the MDS and missing pain assessment interviews.
Report Facts
Residents affected: 3
Sample residents: 24
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding responsibility for ensuring timely and appropriate completion of MDS assessments. |
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