Complaint Investigation

Forest Ridge Health And Rehab Llc

September 8, 2025 · Woodland Park, CO · 16006 W Us Highway 24

Citations 1

CMS Rating 4/5

Beds 80

Provider ID 065418

Healthcare Facility

Forest Ridge Health And Rehab Llc

Woodland Park, CO · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

FOREST RIDGE HEALTH AND REHAB LLC in WOODLAND PARK, CO — inspection on September 8, 2025.

Found 1 citation. 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

FF0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Potential for More Than Minimal Harm

According to the September 2025 CPO, diagnoses included unspecified moderate dementia with agitation, unspecified severity of dementia without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, recurrent depressive disorder and mild neurocognitive disorder due to known physiological condition with behavioral disturbance.

The 5/29/25 MDS assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of two out of 15. 2.

Record reviewReview of Resident #3's EMR did not reveal documentation regarding the physical abuse incident with Resident #1 on 8/16/25.C. Resident #1 (assailant)1.

Record reviewReview of Resident #1's EMR did not reveal documentation regarding the physical abuse incident with Resident #3 on 8/16/25. V.

Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 9/8/25 at 10:10 a.m. LPN #1 said she saw a positive impact when Resident #2 moved to the second floor.

She said the second floor was a more relaxed environment.

She said the residents on the second floor were more cognitively intact and understood that they were not to enter other residents' rooms.

She said Resident #2 kept his door closed at all times, but he ate his meals in the dining room with other residents.

She said Resident #2 started interacting with others and did not exhibit any behavioral problems.

She said there were no incidents when other residents attempted to enter Resident #2's room since he had moved to the second floor.

She said there were no residents with wandering behaviors on the second floor.

She said she had never seen or heard about Resident #2 acting aggressively to staff or other residents. CNA #1 was interviewed on 9/8/25 at 10:30 a.m. CNA #1 said she had been working on the secured unit since June 2025.

She said Resident #2 stayed in his room most of the time and kept his door closed.

She said it was well known that Resident #2 was protective over his room.

She said she did not work on the unit on the day of the incidents between Resident #1 and Resident #2. CNA #1 said she remembered Resident #1 often wandered.

She said Resident #2 had a stop sign banner across his door but he kept it above head level. CNA #1 said Resident #1 usually disregarded the stop banners across doors and he ducked under them.

She said the staff needed to keep an extra set of eyes on him during their shifts and redirect him often.

She said they had two CNAs and one RN on each shift for both hallways.

She said the CNAs and the RN would divide the unit up between themselves to monitor residents.

She said the nurses' station had cameras and the nurse was able to see all of the residents' doors at the same time. CNA #2 was interviewed on 9/8/25 at 11:00 a.m. CNA #2 said a nurse informed her that Resident #1 often wandered.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in WOODLAND PARK, CO, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from FOREST RIDGE HEALTH AND REHAB LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

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.