Bear Creek Senior Living: Illegal Discharge - CO
Bear Creek Senior Living blocked the return of Resident #1 in January following her fourth hospitalization in six months. The facility's interdisciplinary team decided she could not come back because she occasionally refused medications that prevented a serious liver condition.
The resident had been cognitively intact with a perfect score of 15 out of 15 on her mental status assessment as of November 2024. She required supervision for most daily activities but showed no behavioral symptoms, physical aggression, or rejection of care according to her official assessment.
Federal inspectors found the facility violated regulations requiring nursing homes to permit residents to return after hospitalization. The January 30 inspection revealed Bear Creek failed to follow its own policies and federal law governing facility-initiated discharges.
The case began on January 10 when Resident #1 refused her morning medications because her stomach was upset and she feared vomiting. Following management instructions, the nurse called her representative, who came to the facility. The resident then took her medications.
Later that day, the representative requested the resident be sent to a hospital because she appeared lethargic. The assistant director of nursing documented that the resident "appeared to be at her baseline per nursing assessment" but was hospitalized anyway.
Four days later, the facility's team decided not to accept her back. A January 14 interdisciplinary team note stated the facility "was not able to accept her back due to not being able to meet her needs, as the resident would not allow interventions to be put in place to accommodate her safety to prevent abuse physically and verbally."
The resident's medical conditions included alcoholic cirrhosis of the liver, diabetes, major depression, anxiety disorder, and hepatic encephalopathy. She was an above-knee amputee who used a wheelchair and required daily insulin injections along with medications for anxiety, depression, and liver function.
Licensed practical nurse #1 explained the critical nature of one medication during the inspection. The resident's lactulose medication was "very important for her to prevent hepatic encephalopathy," he said. When she declined to take it for several days, "she experienced a mental status change and required hospitalization." The resident refused this medication because "it made her nauseated in the morning."
The facility's own policy contradicted its actions. Bear Creek's transfer and discharge policy states that "residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility." The policy also specifies that "a resident's declination of treatment is not grounds for discharge, unless the facility is unable to meet the needs of the resident or protect the health and safety of others."
The resident's care plan from September 2023 acknowledged she "declined to take her medications and get up in the mornings." The planned interventions included "educating the resident and her family of the possible outcome(s) of not complying with treatment or care."
Despite these documented refusals being a known, ongoing issue with established interventions, the facility chose to bar her return after this hospitalization.
The nursing home administrator told inspectors the team decided not to permit the resident's return "because of her medications refusals." The director of nursing said the decision was made because the resident's medication refusals "led to her mental status changes and hospitalizations."
But the facility failed to follow federal requirements for facility-initiated discharges. Inspectors found no discharge summary, no documentation of resident preparation prior to discharge, and no written discharge notice in the resident's medical record.
The assistant director of nursing admitted to inspectors that "the facility did not send a written facility-initiated discharge notice to Resident #1 and her representative, or to the ombudsman office."
A frequent visitor interviewed during the inspection said she never received a discharge letter from the facility. The resident and her representative "did not receive the discharge notice and were not aware of the appeal rights."
The visitor said the representative "would like to appeal the discharge, however she did not know how to appeal." She told inspectors the representative "would have liked Resident #1 to return to the facility, if she had a chance to appeal the facility's decision of discharge."
Federal law requires nursing homes to provide written notice at least 30 days before a facility-initiated discharge, except in emergencies. The notice must explain the reason for discharge, the effective date, the location where the resident will be transferred, the right to appeal, and contact information for the state long-term care ombudsman.
The facility claimed to have involved PACE (Program of All-Inclusive Care for the Elderly), the ombudsman, the resident's representative, and a hospital caseworker in conversations about the discharge decision. However, inspectors found no documentation of proper notification procedures.
Bear Creek's violation occurred despite the resident's documented cognitive ability and the facility's own acknowledgment that medication refusal had been an ongoing, manageable issue for over a year. The November assessment showed she had no behavioral problems and was not rejecting care overall.
The resident had been admitted initially for long-term care with goals to "evaluate the resident's motivation to return to the community." She had successfully returned to the facility after three previous hospitalizations in 2024 — in August, November, and December.
The pattern of the resident's medication adherence showed she would take medications when her representative was present. On January 10, she initially refused but took them after her representative arrived, suggesting the facility had viable strategies for managing her occasional refusals.
The facility's decision effectively left a cognitively intact resident stranded in a hospital without proper legal recourse. The family's desire to appeal the discharge decision was frustrated by the nursing home's failure to provide required documentation and information about appeal rights.
Federal inspectors classified the violation as causing minimal harm with potential for actual harm, affecting few residents. The inspection was conducted in response to a complaint about the facility's practices.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Bear Creek Senior Living from 2025-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 13, 2026 · Our methodology
BEAR CREEK SENIOR LIVING in COLORADO SPRINGS, CO was cited for violations during a health inspection on January 30, 2025.
Bear Creek Senior Living blocked the return of Resident #1 in January following her fourth hospitalization in six months.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at BEAR CREEK SENIOR LIVING?
- Bear Creek Senior Living blocked the return of Resident #1 in January following her fourth hospitalization in six months.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in COLORADO SPRINGS, CO, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from BEAR CREEK SENIOR LIVING or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 065373.
- Has this facility had violations before?
- To check BEAR CREEK SENIOR LIVING's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.