Forest Ridge Health And Rehab Llc
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
were up against the door inside the room. The nurse told the residents to let each other go and seconds later the staff were able to open the door. Upon entering the room the staff witnessed Resident #1 with his hands on Resident #3's neck and Resident #3 had a hold of Resident #1`s shirt. The certified nurse aide (CNA) was able to separate residents.The investigation documented the incident was witnessed by RN #2 and CNA #3.Resident #1 was placed with a one-to-one caregiver until emergency medical services (EMS) arrived. Resident #3 was assessed and had red marks to his left forearm. The resident was interviewed by
the SSD and said he wanted other residents to stay out of his room. Resident #1 was transported to the emergency room for a psychological evaluation and did not return to the facility. The investigation concluded abuse occurred. B. Resident #3 (victim) 1. Resident statusResident #3, age [AGE], was admitted on [DATE REDACTED].
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.
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FOREST RIDGE HEALTH AND REHAB LLC in WOODLAND PARK, CO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.