Bear Creek Senior Living

F-F626 for failure to permit a resident to return to the facility following a discharge.

On 1/30/25 at 4:50 p.m., the ADON provided a statement that Resident #1's representative was notified verbally by the director of nursing (DON) and the social services director (SSD) of the facility's decision to not readmit the resident after her hospitalization .

-However, the facility failed to provide documentation of the discharge notice and notification to the ombudsman (see interviews below).

Review of Resident #1's EMR revealed the following progress notes:

The 1/10/25 nurses note revealed Resident #1 refused to take her medications because her stomach was upset and she was afraid she would throw up. The note documented that due to the management's previous instruction, the nurse proceeded to call the resident's representative, who came to the facility and the resident took her medications.

On 1/14/25 the ADON documented that on Friday 1/10/25 at 3:45 p.m., Resident #1's representative requested the resident be sent to a hospital, because she said the resident was lethargic. The ADON further documented Resident #1 appeared to be at her baseline per nursing assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 7 065373 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065373 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bear Creek Senior Living 1685 S 21st St Colorado Springs, CO 80904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0623 The 1/14/25 interdisciplinary team (IDT) note documented the IDT team discussed the resident's status at

the hospital. It was determined with the regional nurse that the facility was not able to accept her back due to Level of Harm - Minimal harm or not being able to meet her needs, as the resident would not allow interventions to be put in place to potential for actual harm accommodate her safety to prevent abuse physically and verbally. PACE (program of all-inclusive care for

the elderly), the ombudsman, the resident's representative and the hospital caseworker were involved in the Residents Affected - Few conversation.

Review of Resident #1's EMR on 1/29/25, revealed the following:

-There was no discharge summary or assessment documentation;

-There was no documentation of appropriate orientation and preparation of the resident prior to transfer or discharge; and,

-There was no written discharge notice documentation.

IV. Interviews

A frequent visitor (FV) was interviewed on 1/30/25 at 2:34 p.m. The FV said she did not receive a facility-initiated discharge letter from the facility when Resident #1 was discharged . She said Resident #1 and her representative did not receive the discharge letter and were not aware of the appeal rights. The FV said the resident's representative told her that she would like to appeal the discharge, however she did not know how to appeal.

The DON and the ADON were interviewed together on 1/30/25 at 3:10 p.m. The ADON said the facility did not send a written facility-initiated discharge notice to Resident #1 and her representative, or to the ombudsman office.

The DON said the IDT made the decision of not accepting Resident #1 back due to the resident refusing to take her medications which had led to her mental status changes and hospitalization s.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 7 065373 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065373 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bear Creek Senior Living 1685 S 21st St Colorado Springs, CO 80904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 31229

Residents Affected - Few Based on record review and interviews, the facility failed to allow resident to return to the facility after transfer to a hospital for one (#1) of three residents reviewed for facility-initiated transfers out of three sample residents.

Specifically the facility failed to permit Resident #1 to return after a hospitalization on [DATE REDACTED].

Findings include:

I. Facility policy and procedure

The Transfer or Discharge, Facility-Initiated policy and procedure, undated, was provided by the assistant director of nursing (ADON) on 1/30/25 at 3:20 p.m. It read in pertinent part, Once admitted to the facility, residents have the right to remain in the facility. Facility-initiated transfers and discharges, when necessary, must meet specific criteria and require resident/representative notification and orientation, and documentation as specified in this policy.

Facility-initiated transfer or discharge means a transfer or discharge which the resident objects to, and/or is not in alignment with the resident's stated goals for care and preference.

Residents who are sent emergently to an acute care setting are considered facility-initiated transfers, not discharges, because the resident's return is generally expected.

Residents who are sent emergently to an acute care setting, such as a hospital, are permitted to return to the facility.

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 facility will document that the resident or, if applicable, resident representative, received information regarding the risks or refusal of treatment and that staff conducted the appropriate assessment to determine if care plan revisions would allow the facility to meet the resident needs or protect the health and safety of others.

II. Resident #1

A. Resident status

Resident #1, age greater than 65, was initially admitted on [DATE REDACTED], and readmitted after hospitalization s on 8/15/24, 11/20/24 and 12/24/24 and discharged to the hospital on 1/10/25. According to the January 2025 computerized physician orders (CPO), diagnoses included alcoholic cirrhosis of the liver, type 2 diabetes mellitus with other diabetic kidney complication, acquired absence of left leg above the knee, dependence on wheelchair, type 2 diabetes mellitus with diabetic neuropathy, major depressive disorder, alcohol dependence, in remission, anxiety disorder, hepatic encephalopathy, Parkinsonism and cognitive communication deficit.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 7 065373 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065373 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bear Creek Senior Living 1685 S 21st St Colorado Springs, CO 80904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 The 11/26/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief

interview for mental status (BIMS) score of 15 out of 15. She required supervision for most functional Level of Harm - Minimal harm or activities of daily living (ADL). potential for actual harm

The assessment documented the resident had no behavioral symptoms, including physical, verbal, or other, Residents Affected - Few and there was no rejection of care.

She was administered insulin injections, antianxiety, antidepressant, antibiotic, diuretic and hypoglycemic medications daily.

III. Record review

Review of Resident #1's comprehensive care plan, dated 9/15/23, revealed the following:

-Resident #1 was admitted for long-term care with an intervention to evaluate the resident's motivation to return to the community.

-Resident #1 declined to take her medications and get up in the mornings. The interventions included educating the resident and her family of the possible outcome(s) of not complying with treatment or care.

The 1/10/25 nurses note revealed Resident #1 refused to take her medications because her stomach was upset and she was afraid she would throw up. The note documented that due to the management's previous instruction, the nurse proceeded to call the resident's representative, who came to the facility, and the resident took her medications.

On 1/14/25 the ADON documented that on Friday, 1/10/25 at 3:45 p.m., Resident #1's representative requested the resident be sent to a hospital, because she said the resident was lethargic. The ADON further documented Resident #1 appeared to be at her baseline per nursing assessment.

The 1/14/25 interdisciplinary team (IDT) note documented the IDT team discussed Resident #1's status at

the hospital. It was determined with the regional nurse that the facility was not able to accept her back due to not being able to meet her needs, as she would not allow interventions to be put in place to accommodate her safety to prevent abuse physically and verbally. PACE (program of all-inclusive care for the elderly), the ombudsman, the resident's representative and the hospital caseworker were involved in the conversation.

IV. Interviews

The nursing home administrator (NHA) was interviewed on 1/29/25 at 9:30 a.m. The NHA said the IDT team made the decision to not permit Resident #1's return to the facility because of her medications refusals.

Licensed practical nurse (LPN) #1 was interviewed on 1/30/25 at 1:20 p.m. LPN #1 said the resident's medication, lactulose, was very important for her to prevent hepatic encephalopathy. He said when Resident #1 declined to take this medication for a few days, she experienced a mental status change and required hospitalization . LPN #1 said the resident refused this medication because it made her nauseated in the morning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 7 065373 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065373 B. Wing 01/30/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Bear Creek Senior Living 1685 S 21st St Colorado Springs, CO 80904

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0626 A frequent visitor (FV) was interviewed on 1/30/25 at 2:34 p.m. The FV said she did not receive a facility-initiated discharge letter from the facility. She said Resident #1 and her representative did not receive Level of Harm - Minimal harm or the discharge notice/letter and were not aware of the appeal rights. The FV said the resident's representative potential for actual harm would have liked Resident #1 to return to the facility, if she had a chance to appeal the facility's decision of discharge. Residents Affected - Few

The director of nursing (DON) and the ADON were interviewed together on 1/30/25 at 3:10 p.m.

The DON said the IDT team made the decision of not accepting the resident back due to the resident refusing to take her medications, which led to her mental status changes and hospitalization s.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 7 065373