Life Care Center of Stonegate: Fall Risk Care Failures - CO
The woman was one of two residents at Life Care Center of Stonegate who had serious fractures but no specialized care plans to guide staff in safely moving them, according to federal inspectors who visited the facility in August following a complaint.
Resident #4 told inspectors on August 25 that "staff were not careful with helping her move in bed and she worried about having increased pain in her back because staff were not careful when they assisted her."
The resident had undergone spine surgery but her baseline care plan contained no interventions for her spine fracture or spinal precautions for turning, repositioning or transferring her, inspectors found.
A second resident, identified as Resident #2, had an ankle fracture and required maximum assistance from staff for standing. She had not been evaluated for transfer assistance and mobility assistance needs despite her injury.
The gaps in care planning left frontline staff working without critical safety information.
Certified nurse aide #1 told inspectors she assisted Resident #2 with applying her orthopedic ankle brace but "did not know what to assess to ensure the brace was applied correctly." The aide said she was unaware of specialized care needs for either resident when she helped with transfers and positioning.
Licensed practical nurse #1 said she "was unable to find any baseline care plan interventions for Resident #2 and Resident #4 pertaining to caring for their fractures and immobilized joints."
Both residents had been identified as high fall risks, which should have triggered additional safety protocols. The director of nursing explained that residents with fall risk scores of 10 and above were considered at risk and "should have a care plan initiated with interventions to reduce falls or prevent serious injury if a fall occurred."
Resident #2 had a high risk for falling and "should have had interventions initiated upon admission to prevent falls," the director of nursing acknowledged to inspectors.
The facility had established procedures for communicating fall risk information during shift changes. LPN #1 explained that "when residents were identified as a high risk for falling, the fall risk information was included during the shift-to-shift report so that oncoming staff were able to identify which residents had a high risk of falling."
But the system broke down when it came to fracture-specific care needs.
CNA #1 said she was informed about residents with recent falls, injuries and special care needs during shift reports, but remained "unaware of specialized care needs for Resident #2 and Resident #4 when she assisted with transfers and positioning of the residents."
The director of nursing told inspectors that nurses should routinely check residents with fractures for swelling and circulation, and verify that devices like braces and splints are used safely and properly. She said Resident #4 "should have had spinal precautions in place on her baseline care plan."
When inspectors asked to review the fracture care plans, the director of nursing "was unable to locate baseline care plans for Resident #2 and Resident #4's fracture care."
The missing care plans represented a fundamental breakdown in the facility's system for protecting vulnerable residents. While staff members said they tried to be careful with all residents, they lacked the specific guidance needed to safely handle people with serious injuries.
For Resident #4, recovering from spine surgery, every transfer and repositioning carried the risk of further injury without proper spinal precautions. Her expressed worry about staff causing additional back pain highlighted the real-world consequences of the facility's oversight.
The inspection, conducted in response to a complaint, found that the facility's admission assessment process correctly identified fall risks but failed to translate fracture-related vulnerabilities into actionable care plans that frontline staff could follow.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Life Care Center of Stonegate from 2025-08-25 including all violations, facility responses, and corrective action plans.
Additional Resources
- View all inspection reports for Life Care Center of Stonegate
- Browse all CO nursing home inspections
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
LIFE CARE CENTER OF STONEGATE in PARKER, CO was cited for violations during a health inspection on August 25, 2025.
A second resident, identified as Resident #2, had an ankle fracture and required maximum assistance from staff for standing.
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 LIFE CARE CENTER OF STONEGATE?
- A second resident, identified as Resident #2, had an ankle fracture and required maximum assistance from staff for standing.
- 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 PARKER, 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 LIFE CARE CENTER OF STONEGATE 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 065401.
- Has this facility had violations before?
- To check LIFE CARE CENTER OF STONEGATE'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.