Colorow Care Center
COLOROW CARE CENTER in OLATHE, CO — inspection on May 7, 2025.
Found 2 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
F-F600: failure to protect residents from abuse.
-The 2/18/25 nursing note did not document what kind of injuries were on her arms and where the injuries were on her arms.
-The note did not identify how Resident #3 sustained the old bruising to her arms or when the bruising occurred.
-The review of the resident's EMR did not identify what the old bruising was from or when it occurred.
C.
Staff interviews
The NHA and the director of nursing (DON) were interviewed together on 5/7/25 at 4:03 p.m.
The NHA said Resident #3's injuries to her arms on 2/18/25 were identified after she was involved in a resident-to-resident altercation on 2/17/25.
The NHA and the DON said they did not know what the old bruising was from, when it occurred or if there was old bruising actually present, even though it was documented on a 2/18/25 nursing note.
The NHA and the DON said they were not aware of the bruising/discoloration documented in the 2/4/25 weekly nursing documentation.
The DON said the last known bruising on the resident's arms prior to 2/4/25 was in December 2024 when Resident #3 was combative with care.
The NHA said she reviewed Resident #3's EMR.
The NHA said the 2/4/25 bruising/discoloration to the resident's forearms and the old bruising to the resident's arms, identified on 2/18/25, were not documented anywhere else.
The NHA said the staff should go back into Resident #3's EMR to create a risk management report or document when the bruising was first observed.
065354
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 065354 B.
Wing 05/07/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Colorow Health Care LLC 885 S Hwy 50 Business Loop Olathe, CO 81425
According to the 2/18/25 note, Resident #3 remained in the common area so staff could monitor her safety.
The note indicated Resident #3 continued to be on 15-minute checks to observe and monitor Resident #3's whereabouts and safety.
C. Resident #1 (assailant)
1.
Record review
The 2/17/25 nursing progress note, documented Resident #1 walked to the dining room after the resident-to-resident altercation.
According to the note, Resident #1 was very anxious and restless during the shift.
The note indicated Resident #1 would be monitored of her whereabouts and continue on 15-minute checks.
The 2/21/25 interdisciplinary team (IDT) risk management review note documented Resident #1's physical aggression on 2/17/25 was related to her constipation, anxiety and possible pain.
According to the note her medications were reviewed.
Her bowel medication was discontinued and she was placed on a new bowel medication.
Staff were educated to utilize Resident #1's PRN morphine. Resident #1 was newer to the facility and staff were still learning her behavior triggers. Resident #1 had excessive anxiety which hospice was trying to manage, she had a difficult time communicating and at times would use a white board to communicate.
IV.
Incident of physical abuse of Resident #1 by Resident #4 on 2/28/25
A.
Facility investigation
The facility investigation was provided by the NHA on 5/6/25 at approximately 11:30 a.m.
The investigation documented there was a physical abuse altercation that was witnessed between Resident #1 and Resident #4 on 2/28/25.
The investigation report included three interviews from staff witnesses and notification of the incident to the appropriate parties.
The investigation report documented that neither resident involved in the altercation and no resident witnesses were able to be interviewed due to significant memory impairments. Resident #1, Resident #4, and three other resident witnesses were placed on observation for physical or behavioral changes for 72 hours after the altercation occurred.
065354
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 065354 B.
Wing 05/07/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Colorow Health Care LLC 885 S Hwy 50 Business Loop Olathe, CO 81425