Colorow Health Care Llc

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

to the unit, the unit manager had already cleared all other residents out of the area near Resident #1. The DON said Resident #1 was pushing staff into walls, hitting herself and pulling her hair out. The DON said

the police arrived but were unable to direct Resident #1 to her room and the police officer contacted EMS.

The DON said EMS was also unable to de-escalate Resident #1 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.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/12/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Colorow Health Care LLC

885 S Hwy 50 Business Loop Olathe, CO 81425

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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

on one side while another staff member held her other hand and a third staff member held her legs briefly while LPN #2 provided incontinence care. CNA #1 said that the incident was not a normal situation. CNA #1 said Resident #1 resisted care on other occasions but usually would cooperate if CNA #1 or another staff member tried again a few minutes later. CNA #1 said she never had to hold another resident to complete incontinence care. The DON and the NHA were interviewed together on 8/12/25 at 1:18 p.m. The DON said

during the investigation process of Resident #1's bruises, conducted on 6/6/25, she and other staff members recalled a day approximately three weeks prior, in which Resident #1 was extremely difficult to toilet. The DON said on that day Resident #1 was incontinent of stool and smearing it with her hands all over the common area. The DON said she remembered she and the NHA tried to verbally direct Resident #1 to the bathroom but were not successful. The DON said it was becoming an infection control risk to the unit, so she and another staff member held Resident #1's hands and walked with her to her room. The DON said Resident #1 was cooperative at first, as staff could typically convince Resident #1 to walk to another location with them. The DON said however, when she attempted to prompt Resident #1 to walk to her bathroom, she pulled her legs up putting all of her weight on the DON and the other staff member. The DON said when this happened they assisted her to her bed and then she slid to the floor. The DON 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.

Event ID:

Facility ID:

If continuation sheet