Colorow Care Center
COLOROW CARE CENTER in OLATHE, CO — inspection on August 12, 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
with Resident #1.
The DON said the situation sounded emergent so she called 911.
The DON said
her hair out.
The DON said the police arrived but were unable to direct Resident #1 to her room and
Resident #1 attempted to hit and bite EMS staff.
The DON said the police and EMS spoke with her and told her that Resident #1 was a danger to herself and others and everyone was in agreement that Resident #1 needed to be hospitalized .
The DON said EMS had to give intramuscular haloperidol and use soft restraints to get Resident #1 onto the stretcher.
The DON said she contacted Resident #1’s representative and told her about the situation.
The DON said the resident’s representative said she was not surprised by Resident #1’s aggressive behavior and agreed at the time that Resident #1 needed hospitalization.
The NHA was interviewed again on 8/12/25 at 4:41 p.m.
The NHA said physical abuse could occur any time willful contact was made between two people, even if those people did not intend to harm each other.
The NHA said abuse could also be verbal or sexual and that all reports in which abuse could have occurred were investigated by the facility.
The NHA said when the facility was conducting investigations, they would interview the managers, any staff that witnessed the incident, any staff that were working on that unit and any pertinent residents.
The NHA said Resident #1 was a complex case due to her diagnosis of frontal-lobe dementia.
The NHA said the nurse practitioner for Resident #1 provided education to unit staff about the disease process, including extremely impulsive behavior and rapid mood swings.
The NHA said the facility tried to implement multiple interventions to keep Resident #1, other residents and unit staff safe.
The NHA said an intervention would be successful for Resident #1 for a short period of time and then stop working for no clear reason.
The NHA said the facility planned to be more diligent in their referral process.
The NHA said the current population of the memory care unit could be overstimulating to younger residents with frontal lobe dementia compared to their current population, which was a majority of older residents.
065354 08/12/2025
Colorow Care Center 885 S Hwy 50 Business Loop Olathe, CO 81425
staff member held Resident #1's hands and walked with her to her room.
The DON said Resident #1
bathroom, she pulled her legs up putting all of her weight on the DON and the other staff member.
The
said she and another staff member assisted Resident #1 back on to the bed and when they attempted to provide incontinence care, Resident #1 began to yell, hit and kick the staff.
The DON said she and CNA #1 held the hands of Resident #1, but she was able to move her arms.
The DON said another staff member initially had her arms above Resident #1's legs to block them from kicking LPN #2 who was cleaning, but for brief periods her legs were held.
The DON said all of this happened very quickly and all staff members let go as soon as care was complete.
The DON said Resident #1 stood up and pulled up her own pants after care was complete.
The DON said she did not consider this as a hold because the time period was so brief and the resident could still move her extremities, just not in a way that could injure staff.
The NHA said during the investigation, it was found that the resident's representative was doing most of the care for Resident #1.
The DON said the facility began to have weekly care conferences with Resident #1's family to find more successful interventions and staff on the unit were educated on different approaches to use with Resident #1 to prevent combative behavior.The NHA was interviewed again on 8/12/25 at 4:41 p.m.
The NHA said physical abuse could occur anytime there was willful physical contact between two people, even if those people did not intend to harm one another.
The NHA said a physical restraint could include tie down restraints or isolation.
The NHA said she did not consider the incident with Resident #1 a restraint because she was told Resident #1 could still move her extremities, just not in a way that could harm herself or others.
The NHA said after reviewing the regulation, the events described in the investigation, as well as the other reports of staff members holding Resident #1 to provide care met the definition of a manual hold.
The NHA said she believed some of the verbiage used by staff to describe the events found in the investigation did not accurately reflect the events.
The NHA said after the review of the definitions in the regulation, the NHA said she planned to provide education to the staff on what a manual hold was and to never physically restrict the movement of a resident in order to provide care.
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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.