Wellsprings Care Center: Fall Prevention Failures - CO
The inspection at Wellsprings Care Center, completed September 11, 2025, documented at least six falls by a single resident between late June and late August. Each fall was supposed to trigger a review, a root cause analysis, and updated safety measures. The facility's own timeline, submitted by the nursing home administrator that morning, showed how the interventions accumulated: a floor mat after the July 4 fall, a bed kept at its lowest position after July 7, personal items and the call light kept within reach after July 17, and frequent rounds added after August 11.
The care plan was never updated to reflect the frequent rounds intervention. And for two of the six falls, on August 9 and August 22, the timeline showed no new interventions at all, and no documentation that anyone had reviewed whether new ones were needed.
A certified nursing assistant, CNA #2, told inspectors on September 9 that she knew the fall mat and the low-bed position were interventions for the resident. But she said she did not know where to find his fall interventions in the electronic medical records system. She learned about new interventions verbally, when a nurse manager told her.
The regional clinical resource, interviewed two days later, said staff were provided education on fall interventions and how to locate them in the resident's care plan. What she described as standard practice and what CNA #2 described as her actual experience were not the same thing.
The nursing home administrator acknowledged it directly. She said the care plan should have been updated after the August falls. She said staff should know where to find the interventions. She said both things on September 11, the last day of the inspection, after the gap had already been documented.
A licensed practical nurse interviewed on September 9 described the fall interventions for the same resident as using a fall mat when he was in bed. She did not mention keeping the bed in its lowest position, which had been added as an intervention after the July 7 fall, more than two months earlier.
The inspection also documented concerns about two other residents who smoked independently. The activities director told inspectors she kept the lighter used by one of them, Resident #48, while the nurses kept his cigarettes. For Resident #68, she said throwing cigarettes on the ground instead of into an ashtray was not an uncommon behavior, that he was hard to redirect, and that he had been educated on using the ashtray. CNA #2 said neither resident had any behaviors related to smoking. The activities director's account and the CNA's account described two different residents.
The nursing home administrator said she was unaware of the smoking issues involving either resident when she was interviewed. She also said that even residents classified as independent smokers should be periodically observed for safe smoking practices.
What the inspection captured, across multiple interviews and records, was a facility where the formal systems for managing known risks had broken down in specific and traceable ways. The interdisciplinary team held morning meetings to review falls. A regional clinical resource described a careful process of reviewing prior interventions, determining why they failed, and adding new ones. The administrator could articulate what should have happened after every fall.
The resident fell six times anyway. His care plan sat unrevised. The aide who helped him every day didn't know where to look for his safety instructions. And two months of falls, from June through August, produced a timeline that the facility handed over only on the final morning of the inspection.
There is no indication in the inspection record of what happened to the resident after August 22.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Wellsprings Care Center from 2025-09-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
WELLSPRINGS CARE CENTER in ENGLEWOOD, CO was cited for violations during a health inspection on September 11, 2025.
The inspection at Wellsprings Care Center, completed September 11, 2025, documented at least six falls by a single resident between late June and late August.
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.