Life Care Center of Stonegate: Skull Fracture Fall - CO
Resident #4 was found bleeding on the floor next to her bed on August 19, with a laceration on the back of her head. Staff called 911 and she was rushed to the emergency department, where doctors diagnosed an open fracture of the temporal skull bone.
She returned to the facility three days later at her usual level of cognition, according to hospital records.
The 83-year-old had a fall risk score of 22, well above the facility's threshold of 10 for high-risk residents requiring special interventions. She was confused and routinely wanted to get out of bed earlier than her normal schedule, the Director of Nursing told federal inspectors.
But nobody had checked whether she understood how to call for help.
During the August 25 inspection, Resident #4 could not locate her call light when asked by investigators. She told them she didn't know if she would remember to use it to call staff for assistance.
The facility's investigation concluded she fell because "the resident got out of bed without assistance when the resident believed it was time to get out of bed for the day."
Licensed Practical Nurse #1 explained the facility's fall prevention process to inspectors. When residents are admitted, nurses assess their fall risk and create baseline care plans with prevention interventions. Information about high-risk residents gets passed along during shift reports so oncoming staff know which patients need extra attention.
Certified Nurse Aide #1 said she knew which residents were fall risks because she was familiar with patients on her unit. She believed every resident had some fall risk and made sure call lights and personal items stayed within reach.
The Director of Nursing said newly admitted residents receive room orientation and instruction about call light locations. Staff ask them to demonstrate they can press the button to call for assistance.
However, the facility's call light orientation included no specific steps to ensure cognitively impaired residents retained understanding or could later locate and activate the device without staff help.
This gap proved critical for Resident #4, who was confused and had established patterns of wanting to get up at irregular times.
After her return from the hospital, the facility updated her fall care plan to include wearing grip socks at all times. But inspectors found no documentation that staff had assessed whether she now understood how to locate and activate her call light to request assistance when she wanted to get out of bed.
The Director of Nursing acknowledged during the interview that Resident #4 should have had fall prevention interventions initiated upon admission given her high risk score.
Federal inspectors cited the facility for failing to provide adequate supervision and assistive devices to prevent accidents. The violation resulted in actual harm to few residents.
Resident #4's case illustrates a fundamental breakdown in fall prevention protocols designed to protect vulnerable residents. Despite identifying her as high-risk and documenting her confusion and irregular sleep patterns, staff never verified she possessed the cognitive ability to safely request help.
The three-day hospitalization and skull fracture represent consequences that proper assessment and intervention might have prevented. Her continued inability to locate her call light after returning from the hospital suggests the underlying problem remained unaddressed even after the serious injury occurred.
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
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 20, 2026 · Our methodology
LIFE CARE CENTER OF STONEGATE in PARKER, CO was cited for violations during a health inspection on August 25, 2025.
Resident #4 was found bleeding on the floor next to her bed on August 19, with a laceration on the back of her head.
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.