GRAND JUNCTION, CO - Federal inspectors cited Eagle Ridge Post Acute for causing actual harm to a resident who lost 26 pounds over three months while the facility failed to implement nutrition interventions or even weigh her for more than four months. The June 2024 complaint investigation also uncovered widespread infection control breakdowns affecting many residents.
Resident Lost 17.4% of Body Weight Without Intervention
A long-term care resident at Eagle Ridge Post Acute was admitted in November 2023 weighing 149 pounds. By February 5, 2024, her weight had dropped to 123 pounds — a loss of 26 pounds representing 17.4% of her body weight in three months. In clinical terms, a weight loss exceeding 7.5% in three months is classified as severe, meaning this resident's loss was more than double that threshold.
The weight loss trajectory was documented in the facility's own records. The resident weighed 135.2 pounds upon readmission from a hospital stay in January 2024, then dropped to 123.6 pounds by January 22 — a loss of 12.2 pounds (9%) in a single month, which alone qualifies as severe.
Despite these alarming numbers, the facility took no meaningful action. No new nutrition interventions were implemented after the severe weight loss was recorded on February 5, 2024. The physician's order for weekly weigh-ins was discontinued on February 6 — one day after the severe loss was documented — and the facility did not obtain another weight for more than four months.
The registered dietitian told inspectors she had verbally requested nursing staff to obtain additional weights but did not document these requests. "I did not know why the significant weight loss was not identified or followed up on," the dietitian said during her interview.
Bland Food Contributed to Skipped Meals
The resident herself pointed to the food as a contributing factor. She reported that she was repeatedly served bland scrambled eggs for breakfast despite her documented preference for fried or poached eggs and spicy foods. She told inspectors she "skipped several meals throughout the week" because the food did not taste good and "often felt very hungry by lunch time."
During the survey, inspectors observed her breakfast tray with scrambled eggs sitting untouched. The food quality issue was not isolated to one resident — multiple residents described the facility's food as "awful," "bland," and "processed." A test tray evaluation found lima beans served at 103 degrees Fahrenheit (below the 135-degree standard for hot foods), garlic toast that was partially burnt, and chocolate pudding at 54.5 degrees (above the 41-degree maximum for cold foods).
The director of nursing acknowledged the facility failed to identify the significant weight loss and said interventions such as nutritional supplements "could have been offered." She also confirmed the facility's quality assurance committee had identified weight documentation as a problem but had not implemented a correction plan.
Unreported Fall Left Resident With Facial Injuries
Inspectors also found the facility failed to properly manage fall risks for a rehabilitation resident. The resident fell while smoking alone outside the facility at approximately 1:00 or 2:00 a.m. — a violation of the facility's supervised smoking policy, which required staff presence during smoking. Her scooter cushion slipped, and she struck her face on the concrete.
A CNA discovered the resident on the ground after 10 to 15 minutes. The resident told inspectors she "begged the nurse not to report the fall" because she was close to being discharged home. The nurse agreed, telling the resident "she hated doing accident reports."
The fall was never documented. The resident developed visible bruising under her eye that spread down her cheek. A CNA noticed the injury and reported it to the nurse, but the nurse did not notify the director of nursing. The resident was discharged without any documentation of the fall, the facial injuries, or a post-fall assessment.
Infection Control Failures Across the Facility
The inspection revealed systemic infection control problems affecting many residents. Housekeeping staff were observed wiping disinfectant off surfaces immediately after spraying — failing to allow the manufacturer's required 60-second dwell time for bacterial kill (and eight minutes for C. difficile). Both housekeepers told inspectors they had not received cleaning training in their preferred language, Spanish, creating a communication barrier with supervisors.
Staff were repeatedly observed providing direct care to residents on enhanced barrier precautions without wearing required personal protective equipment. One CNA told inspectors she "did not know what enhanced barrier precautions were" or which residents required PPE.
In one case, a nurse completed a wound dressing change and placed the resident's freshly bandaged leg back onto a blood- and fluid-soaked bed sheet. That soiled linen remained unchanged for more than 24 hours.
The facility also lacked a compliant water management program for Legionella prevention. The director of maintenance told inspectors the responsibility "was given to him a week prior to the survey" and he had received no guidance or training. The regional operations manager confirmed the facility was not in compliance.
Readers can review the full inspection report for additional details on all cited deficiencies at Eagle Ridge Post Acute.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Eagle Ridge Post Acute from 2024-06-12 including all violations, facility responses, and corrective action plans.
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