Life Care Center Of Colorado Springs
LIFE CARE CENTER OF COLORADO SPRINGS in COLORADO SPRINGS, CO — inspection on February 26, 2026.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
toileting schedule, but said when she was working she toileted Resident #18 every two hours.The
choking, falls with major injury, elopements, burns, leaving the facility against medical advice, and
begin documentation by immediately completing a risk assessment.
She said if the event was witnessed, then staff were to take statements from the resident and anybody else involved.
The DON said making necessary notifications to the provider and family would be next as part of the investigation process.
The DON said the root cause analysis of an incident was important because it helped to determine the cause of the incident and how to treat immediately to ensure the incident did not happen again.
The DON said the facility put a lot of interventions in place to prevent Resident #18 from falling.
The DON said Resident #18 was very impulsive due to his diagnoses.
The DON said Resident #18 scored high on his BIMS assessment; however, his safety awareness was not present.
The DON initially recalled the CNA was in the shower room with the resident at the time of the 12/16/25 fall.
However, once she reviewed the 12/16/25 event progress note, the DON discovered that the CNA had left Resident #18 alone in the shower room.
The DON confirmed the CNA was outside of the shower room for a few minutes.
The DON said a resident was allowed, per the facility policy, to be left alone in the shower room only if a resident was alert and oriented.
She said an alert and oriented resident did not have to be attended in the shower room, but staff was to check on the resident every five minutes.
The DON said the CNA was educated on 12/16/25 by the RN.
The DON said a resident with a diagnosis of high falls should not be unattended in the shower room.
The DON said post-fall, the RN on duty should complete the head to toe assessment (skin, pain, fall, neuro's if the fall was unwitnessed) before doing anything else with the resident.
The DON said the nurses should document this in a progress note.
The DON said the licensed practical nurses (LPN) could complete the initial assessment of the fall, but the RN had to be the one who completed the head to toe assessment.The DON said on the days Resident #18 had multiple falls, there was nothing more the facility could do, and the DON said she started calling staff to come and provide one-to-one supervision with Resident #18.
The DON said that was why there was a significant decrease in his falls after 12/10/25.
The DON said the resident's family also hired a private sitter to come in and sit with Resident #18 on the days the resident's wife could not make it or family and friends were not available.
The DON said the facility attempted to offer Resident #18 a soft helmet and busy board, but his wife did not want either of those for dignity reasons.
The DON said the facility arranged an appointment for the resident to see the neurological ophthalmologist.
The DON said Resident #18 was complex and not appropriate for this setting.
The DON said Resident #18's entire frontal lobe had been compromised and the resident was very impulsive as a result.
The DON said residents had a right to fall and the facility had an obligation to try to keep the residents as safe as possible.
The DON said the facility completed a high risk audit on all the residents that were high fall risks.
She said the environmental audits were completed by the DON or unit manager.
The DON said on grand rounds they asked staff who they thought was going to fall next, and any concerns about residents falling.
The DON said CNAs could find a resident's fall interventions on the Kardex (comprehensive care tool.
The DON said RNs would find interventions on the residents' care plans.
The DON said CNAs did walking rounds, and fall huddles were done with all the staff.
The DON said she created a fall binder back in December 2025 after the high volume of falls.
The DON said the binder was placed at each nurses' station.
She said the binder included a fall checklist which was a packet that each RN was to complete after a fall and give to the DON.
The DON said the fall packet included a fall checklist, neurological assessment forms, resident and RN sign offs for interventions and education, and witness interview forms.
The nursing home administrator (NHA) was interviewed on 2/26/26 at 6:45 p.m.
The NHA said he was aware of Resident #18 being a high fall risk.
The NHA said Resident #18 had a right to fall but he said he also knew the facility had a responsibility to ensure Resident #18's safety.
The NHA said he was aware of Resident #18's impulsivity.
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Life Care Center of Colorado Springs 2490 International Cir Colorado Springs, CO 80910
Based on observations and interviews the facility failed to ensure all drugs and biologics used in the
labeling.
Specifically the facility failed to ensure over the counter (OTC) medications were discarded after the expiration date.
Findings include:I.
Facility policy and procedureThe House Stock Items policy, revised 9/15/24, was provided by the director of nursing (DON) on 2/25/26 at 4:05 p.m. It read in pertinent part, The facility should post the house stock medication list in an appropriate location such as medication rooms or a medication administration binder.
The facility should ensure that house stock medications are stored in the original manufacturer's container.
The medication name, strength, expiration date and lot number should be clearly visible.II.
ObservationsOn 2/24/26 at 5:01 p.m. the medication cart on the 300 east hall was observed with licensed practical nurse (LPN) #4.
The following items were found:A bottle of OTC CoQ10 100 milligrams (mg) supplement had a manufacturer's expiration date of 1/24/26.A bottle of OTC Calcium 500 mg had a manufacturer's expiration date of 1/30/26. A bottle of OTC Acetaminophen 500 mg had a manufacturer's expiration date of 12/30/25.III.
Staff interviewsRegistered nurse (RN) #4 was interviewed on 2/24/26 at 4:50 p.m. RN #4 said she had worked at the facility for approximately two years.
She said she was trained to write the date of when the OTC medications were opened.
She said she was trained by the facility to discard the OTC medications three months after the open date that was written on the bottle. LPN #4 was interviewed on 2/24/26 at 5:01 p.m. LPN #4 said she was unsure of whether OTC medications expired 30 days after opening or according to the manufacturer's expiration date on the bottle.
She said she did not know where to locate the OTC storage and expiration policy for the facility.
She said she was unsure why nursing staff were writing the open date on the OTC medication bottles.
She said if the expiration date on the manufacturer's bottle had passed then the medication should be discarded.
The director of nursing (DON) was interviewed on 2/24/26 at 5:38 p.m.
The DON said the nursing staff were expected to reference the manufacturer's date on the OTC medication bottles.
She said all the nurses were trained by other bedside nursing staff.
She said the facility did not provide any specific training on medication expiration dates of medications, whether the medications were from the pharmacy or OTC medications.
The DON said all nursing staff should be properly trained and demonstrate competency for nursing medication tasks prior to performing medication administration.
The DON said this was important to maintain resident safety.
She said expired medications should not be administered to residents for safety reasons because expired medications could make a resident very sick.
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Life Care Center of Colorado Springs 2490 International Cir Colorado Springs, CO 80910
hospice team.-However, neither Resident #41's electronic medical record (EMR) nor her physical
hospice services company was not good at communicating with the facility, but the facility was
appropriately for the residents.
The DON said the facility had been searching for other hospice services companies to work with.
charting to verify and again said Resident #109 was not on EBP
resident had any type of indwelling medical device, or MDRO infection.
The IP said she was just made
been a busy week.
The IP said the process for establishing EBP was determined at the time of a resident's admission.
The IP said the facility's admission team would inform her of an EBP and then she added it to the resident's chart.
065356 02/26/2026
Life Care Center of Colorado Springs 2490 International Cir Colorado Springs, CO 80910