Wellsprings Care Center
WELLSPRINGS CARE CENTER in ENGLEWOOD, CO — inspection on September 11, 2025.
Found 6 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
said their room was not cleaned everyday.
she did not have soap or towels in her bathroom.
She said she did not feel these items were replaced
C.
Staff interviews The MTD was interviewed on 9/8/25 at 12:28 p.m.
The MTD said he was not aware of the floor issue in room [ROOM NUMBER] until it was brought to his attention during the survey. He said the loose tiles and brown liquid could be from mopping the floors and the water settled in between the tiles and became rusty. He said the brown fluid could have been there for quite awhile.
The MTD said the floor was an easy fix and he would replace the tiles.
The MTD said the residents' rooms were cleaned daily with the floors being mopped, bathrooms cleaned and wiping down of surface areas. He said the rooms were scheduled for monthly deep cleans, which had a more in-depth cleaning checklist.
The floor technician was interviewed on 9/9/25 at 11:52 a.m.
The floor technician said the smell coming from the floor in resident room [ROOM NUMBER] was urine seeping from under the tiles.
The NHA was interviewed on 9/10/25 at 1:00 p.m.
The NHA said the liquid under the tiles was not rusted water but urine.
She said the residents should have been moved out of the room until all the affected areas in the room were cleaned and treated.
She said she would have them moved to complete the maintenance on the floor properly.
HK #2 was interviewed on 9/11/25 at 9:30 a.m.
She requested for another staff member, the social services assistance (SSA), to interpret because she read and spoke very little English. HK #2 said she did not have a cleaning checklist on her cart.
She said there was a checklist for rooms that received a deep clean.
She said the checklist was filled out after the shift.
She said the checklists were kept in a binder in the MTD's office. HK #2 said the checklist and the cleaning bottles on her cart were written in English.
065208 09/11/2025
Wellsprings Care Center 3636 S Pearl St Englewood, CO 80113
position. -There was no risk management review note documented for the falls on 8/11/25 on
#5's needs, ensure his call light was within reach, review past falls to determine the root cause,
were added to his EMR.On 7/4/25 the new intervention post 7/4/25 fall was to ensure a floor mat was next to the left side of Resident #5's bed.On 7/8/25, the new intervention post fall on 7/7/25 was to keep the resident's bed in the lowest position at all times when the resident was in bed.On 7/17/25 the new interventions post fall on 7/17/25 were to ensure the resident's personal items including water, snacks and call light were within reach.On 8/18/225 the new intervention post fall on 8/11/25 was frequent rounds.-However, the care plan was not updated with the frequent round intervention (see care plan above). -The timeline provided failed to reveal new interventions for the falls on 8/9/25 or 8/22/25 or documentation that the falls were reviewed to determine if new interventions were needed.IV.
Staff interviewsLicensed practical nurse (LPN #1) was interviewed on 9/9/25 at 11:40 a.m. LPN #1 said Resident #48 and Resident #68 were both independent smokers and kept their own smoking materials.
She said Resident #5 was a fall risk and the fall interventions for him were to use a fall mat when he was laying in bed. -LPN #1 did not indicate if the resident's bed should be in the lowest position when the resident was in bed (see observations and care plan above).CNA #2 was interviewed on 9/9/25 at 11:47 a.m. CNA #2 said Resident #48 was an independent smoker and kept his own cigarettes and lighter.
She said he did not have any behaviors regarding smoking. CNA #2 said Resident #68 was an independent smoker and kept his own cigarettes and lighter.
She said he did not have any behaviors regarding smoking. CNA #2 said the fall interventions for Resident #5 were to keep the fall mat on his floor and to keep his bed in the lowest position when he was lying in bed. CNA #2 said when the nurse managers puts new fall interventions into the resident's EMR, they communicated the new interventions to the staff verbally and she said she did not know where to find the fall interventions in Resident #5's EMR.
The activities director (AD) was interviewed on 9/9/25 at 10:55 a.m.
The AD said she kept the lighter that Resident #48 used and the nurses kept his cigarettes.
She said throwing cigarettes on the ground instead of the ashtray was not an uncommon behavior for Resident #68.
The AD said he was hard to redirect and had been educated on putting cigarettes in the ashtray.
The regional clinical resource (RCR) was interviewed on 9/11/25 at 9:54 a.m.
The RCR said the process post-fall was for a registered nurse (RN) to assess the resident.
The RCR said the RN would attempt to determine the root cause of the fall and talk to the resident.
She said the clinical interdisciplinary team (IDT) reviewed falls in the morning meeting and tried to determine the root cause of the falls and establish fall interventions.
The RCR said the IDT would review the prior interventions, why those interventions were not effective and look at adding new interventions.
She said staff were provided education on fall interventions and how to find the interventions in the resident's care plan.-However, CNA #2 said she did not know where to find fall intervention for residents (see interview above).
The nursing home administrator (NHA) was interviewed on 9/11/25 at 12:11 p.m.
The NHA said that after each fall, the IDT evaluated the root cause, interventions used, whether the interventions were effective or not and new interventions to try.
The NHA said Resident #5's care plan should have been updated after the facility initiated new interventions and she acknowledged the care plan should have been updated after Resident #5's August 2025 falls and the staff should know where to find the interventions.
The NHA said even residents who are independent smokers, should be periodically observed for safe smoking practices.
She was unaware of Resident #48 and #68's smoking issues.
065208 09/11/2025
Wellsprings Care Center 3636 S Pearl St Englewood, CO 80113
Review of Resident #59's September 2025 CPO revealed the resident had a physician's order for Paliperidone EC 6 mg tablet.
Take 2 tablets in the afternoon. -However, RN #2 dispensed one tablet of Paliperidone to Resident #59 during the morning administration pass (see observation above).IV.
Staff interviewsThe regional clinical resource (RCR) was interviewed on 9/11/25 at 2:30 p.m.
The RCR said a lower dose of an administered medication could lessen the effect of the medication.
The RCR confirmed Resident #59's order for Paliperidone was for two tablets instead of one tablet.
The RCR said Resident #31's physician's order for Aspirin read chewable tablets, however, she said the resident did not need a chewable table.
065208 09/11/2025
Wellsprings Care Center 3636 S Pearl St Englewood, CO 80113
medication cart. LPN #3 picked up the cup of water and the medication cup containing Resident #24's
medication. LPN #3 threw the cup of water and the medication cup away and exited Resident #24's
-LPN #3 did not perform hand hygiene during the preparation of Resident #24's medication, upon entering the resident's room or upon exiting the resident's room.
C.
Staff interviews RN #2 was interviewed on 9/10/25 at 9:31 a.m. RN #2 said hand hygiene should be performed before, during and after medication preparation.
She said hand hygiene should also be performed before and after medications were administered to a resident. RN #2 said hand hygiene should be performed to decrease the risk of transmitting organisms and help reduce the risk of infection.
LPN #3 was interviewed on 9/10/25 at 1:17 p.m. LPN #3 said hand hygiene should be performed before and after all resident care. LPN #3 said hand hygiene was important because it helped decrease the risk of infection.
The RCR was interviewed on 9/11/25 at 2:30 p.m.
The RCR said facility staff were supposed to perform hand hygiene when going in and out of a resident room and also between glove use.
The RCR said proper hand hygiene was important to help prevent the transmission of organisms.
065208 09/11/2025
Wellsprings Care Center 3636 S Pearl St Englewood, CO 80113
the facility for six months, and the substance on the wall had been there since she was hired. HK #1
while touring the shower rooms.
The NHA and the regional maintenance director could not identify the black substance on the wall in the first floor shower room (nearest to the business office) or the black substance in the second floor shower room (nearest to resident room [ROOM NUMBER]) in the place of the missing caulking.
The regional maintenance director said the black substance in both shower rooms should have been inspected and tested for possible mold.
The NHA said it was her expectation that a work order would be written for a leaking shower head to prevent water damage from prolonged dripping and that any suspicious black substance in the shower rooms would be tested for identification and treatment.
065208 09/11/2025
Wellsprings Care Center 3636 S Pearl St Englewood, CO 80113
windows, or mechanical ventilation for two out of four shower rooms.
Specifically, the facility failed
Findings include:A.
Professional referenceAccording to the U.S.
Department of Energy's Office of Energy Efficiency and Renewable Energy, April 2021 retrieved on 9/19/25 from: https://docs.nrel.gov/docs/fy21osti/79150.pdf., Proper ventilation helps reduce the concentration of bioaerosols (bioaerosols consist of aerosols originated biologically such as metabolites, toxins, or fragments of microorganisms), which can be particularly important in nursing homes due to the presence of vulnerable adults.
Good ventilation can improve the health and wellbeing of the residents by reducing infection risks and preventing respiratory issues. By ensuring proper ventilation, nursing homes can significantly enhance the safety and quality of life for their residents. B.
Observations On 9/7/25 at 7:28 a.m. during the initial walk through of the shower rooms, the following was observed:The first floor tub and shower room, nearest to the business office, revealed there was no air flow coming from the ventilation fan in the shower room.
The ventilation fan wall cover was covered with a thick layer of what resembled gray dust.
The first floor shower room, nearest to resident room [ROOM NUMBER], revealed there was no air flow coming from the ventilation fan in the shower room.On 9/9/25 at 11:35 a.m. the following was observed:The first floor tub and shower room, nearest to the business office, revealed there was no air flow coming from the ventilation fan in the shower room.
The ventilation fan wall cover was covered with a thick layer of what resembled gray dust.
The first floor shower room, nearest to resident room [ROOM NUMBER], revealed there was no air flow coming from the ventilation fan in the shower room.C.
Staff interviewsThe regional maintenance director was interviewed on 9/11/25 at 11:30 a.m. while touring the shower rooms.
The regional maintenance director said the facility used a mechanical ventilation system. He said the ventilation system prevented condensation risks by pulling moisture laden air out of the room.
The regional maintenance director said if a ventilation system was not operational in a humid environment, it could contribute to the growth of mold. He said to ensure the ventilation system was working properly in the rooms and shower rooms, a piece of paper could be put up to the vent and if there was proper air flow, the paper would be pulled to the vent.
The regional maintenance director said the ventilation fan and cover should be cleaned every six months.
After inspecting the first floor tub and shower room ventilation cover, the regional maintenance director acknowledged there was not any air flow and the ventilation cover had not been cleaned within the last six months.
After inspecting the first floor shower room ventilation cover, the regional maintenance director acknowledged there was not any air flow.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.