Life Care Center Of Stonegate

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

maximum assistance from staff for standing. The resident was not evaluated for transfer assistance and mobility assistance needs.B. Resident interviewResident #4 was interviewed on 8/25/25 at 2:03 p.m.

Resident #4 said staff were not careful with helping her move in bed and she worried about having increased pain in her back because staff were not careful when they assisted her. C. Record review -Review of Resident #4's baseline care plan revealed the care plan did not include interventions for spine fracture or spinal precautions following the resident's post-operative care following spine surgery while turning, repositioning or transferring the resident. III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/25/25 at 2:12 p.m. LPN #1 said when residents were admitted to the facility they were assessed to determine their risk for falling. LPN #1 said when a resident had a risk for falling, the admitting nurse completed a baseline care plan for fall prevention and initiated fall prevention interventions. LPN #1 said the fall prevention interventions were assigned to nurses and certified nurse aides (CNA) for monitoring and observations as indicated by the intervention. LPN #1 said when residents were identified as a high risk for falling, the fall risk information was included during the shift-to-shift report so that oncoming staff were able to identify which residents had a high risk of falling. LPN #1 said she was unable to find any baseline care plan interventions for Resident #2 and Resident #4 pertaining to caring for their fractures and immobilized joints.CNA #1 was interviewed on 8/25/25 at 2:30 p.m. CNA #1 said she was informed about residents with recent falls, injuries and special care needs during the shift-to-shift reports.

CNA #1 said she was unaware of specialized care needs for Resident #2 and Resident #4 when she assisted with transfers and positioning of the residents. CNA #1 said she assisted Resident #2 with applying her orthopedic ankle brace but she did not know what to assess to ensure the brace was applied correctly. CNA #1 said she was careful with all the residents. The director of nursing (DON) was interviewed

on 8/25/25 at 3:03 p.m. The DON said when residents were admitted to the facility, they had a fall risk assessment completed by the admitting nurse and were assigned a fall risk score. The DON said that every resident with a score of 10 and above was considered to be a fall risk and should have a care plan initiated with interventions to reduce falls or prevent serious injury if a fall occurred. The DON said Resident #2 had

a high risk for falling and should have had interventions initiated upon admission to prevent falls.The DON said nurses should check and assess residents that had fractures for swelling, circulation and check devices (braces/spints) for safety and proper use. The DON said Resident #4 should have had spinal precautions in place on her baseline care plan. The DON said she was unable to locate baseline care plans for Resident #2 and Resident #4's fracture care.

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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

08/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Life Care Center of Stonegate

15720 Garden Plaza Dr Parker, CO 80134

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 0689 Level of Harm - Actual harm Residents Affected - Few

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

The nurse documented Resident #4 remained conscious and was assisted to her bed until she was transferred to the hospital.The 8/19/25 fall investigation revealed Resident #4 was found on the floor next to her bed and was bleeding from a laceration on the back of her head. Staff provided first aid, called 911, and Resident #4 was transferred to the emergency department for evaluation. Resident #4 was diagnosed with

an open skull fracture, and returned to the facility on 8/22/25. The facility investigation determined the cause of the fall was the resident got out of bed without assistance when the resident believed it was time to get out of bed for the day. The 8/22/25 hospital summary documented that Resident #4 was diagnosed with an open fracture of the temporal (skull) bone and was at her usual level of cognition.On 8/22/25 the facility updated Resident #4's fall care plan that included wearing grip socks at all times.-There was no documentation that Resident #4 was assessed for understanding that she could locate and activate a call light to request assistance when she wanted to get out of bed (see DON interview below). IV. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/25/25 at 2:12 p.m. LPN #1 said when residents were admitted to the facility they were assessed to determine their risk for falling. LPN #1 said when a resident had a risk for falling, the admitting nurse completed a baseline care plan for fall prevention and initiated fall prevention interventions. LPN #1 said the fall prevention interventions were assigned to nurses and certified nurse aides (CNA) for monitoring and observations as indicated by the intervention.

LPN #1 said when residents were identified as a high risk for falling, the fall risk information was included

during the shift-to-shift report so that oncoming staff were able to identify which residents had a high risk of falling.CNA #1 was interviewed on 8/25/25 at 2:30 p.m. CNA #1 said she knew which residents were at risk for falling because she was familiar with the residents on her assigned unit. CNA #1 said she thought every resident had a risk of falling and she made sure residents had their call lights and personal items within their reach. CNA #1 said she was informed about residents with recent falls, injuries and special care needs

during the shift-to-shift reports. The DON was interviewed on 8/25/25 at 3:03 p.m. The DON said when residents were admitted to the facility, they had a fall risk assessment completed by the admitting nurse and were assigned a fall risk score. The DON said that every resident with a score of 10 and above was considered to be a fall risk and should have a care plan initiated with interventions to reduce falls or prevent serious injury if a fall occurred. The DON said Resident #2 had a high risk for falling and should have had interventions initiated upon admission to prevent falls.The DON said Resident #4 had a fall risk score of 22 and had a high risk for falling. The DON said Resident #4 was confused and wanted to get out of bed earlier and get dressed earlier than her normal routine. The DON said when residents were admitted to the facility, they were oriented to their rooms and received instruction regarding where their call lights were located and residents were asked to demonstrate that they could press the button to call for assistance. -However, Resident #4 was unable to locate her call light during observation and said she did not know if

she would remember to use the call light to call staff (see observation above).The DON said the room and call light orientation did not include specific steps to ensure a cognitively impaired resident retained understanding and could later locate and activate the call light without staff assistance.

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