Bear Creek Senior Living

An administrative relicensure survey was completed on 4/22/26. No deficiencies were cited.A change of ownership occurred on 12/29/25. THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary.The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers.

A licensure complaint, prompted by #CO40901, was completed on 9/9/25. A deficiency was cited. Based on record review and interview the residence failed to comply with all federal and state laws andregulations relating to storage of controlled substances affecting 23 current residents in the secured environment.Findings IncludeFormer Resident #5 was admitted to the residence on 7/18/24 with a diagnosis of dementia.A disciplinary action form dated 9/2/25 read that Staff #1 left the medication cart unlocked and a resident hadaccess to the medication cart.On 9/9/25 at approximately 8:00 a.m., Staff #5 stated that she was present when Former Resident #5 was foundwith the medication. She stated that the medication belonged to Resident #2 and that the medication was fentanylpatches. She stated that all of the medication was found and accounted for and that Former Resident #5 did notuse any of the medication. On 9/9/25 at approximately 9:30 a.m., the Memory Care Care Coordinator stated that she was notified of thefentanyl patches missing on 8/28/25, a day after the incident, because she was on leave the day that it happened.She stated that she provided Staff #1 with a verbal warning and retraining. She stated that she then reached out tothe pharmacy to have the medication cart fixed or replaced in order to prevent future incidents. On 9/9/25 at approximately 10:00 a.m., Staff #1 stated that she was working the medication cart and thought sheshut and locked the medication cart before walking away. She stated that the door of the medication cart wasknown for not latching all the way, and this must be what happened because she then noticed during shift changeand narcotic count that Resident #2' s fentanyl patches were not there. She stated that she knew it must be FormerResident #5 because she was known for lingering near the medication cart to take things that this was one of herbehaviors. Staff #1 stated that upon discovering the missing medication, she immediately searched FormerResident #5' s room and found all of the missing medication, and it was all untampered and intact. On 9/9/25 at 1:10 p.m., the administrator..

A relicensure survey with complaint #CO34185 was completed on 12/11/24. Deficiencies were cited. Based on observation and interview, the residence failed to ensure the administrator completed 40 hours of training as required, affecting 116 current residents.On 12/11/24, documentation of the administrator' s 40-hours of administrator training was requested but not provided.On 12/11/24 at 8:15 a.m., the administrator stated that she had not completed the required 40-hour administrator training. She added that she had a waiver for the training since she was a nursing home administrator. However, she stated she was unable to provide the waiver. She stated that nursing facilities and assisted living residences had different regulatory requirements. On 12/11/24 at 8:17 a.m., the regiona.. Based on observation and interview, the residence failed to make available, either directly or indirectly, a physically safe environment, affecting 25 current residents in the secure environment (SE). Findings include:The residence' s undated Orientation and Policy training document read that all staff were trained to maintain a safe, healthy environment.On 12/11/24, the actuator on the screen door that led from the SE to the outdoor smoking area was loose and sticking out of the door approximately one foot above the ground. This presented a hazard to residents who would go outdoors.On 12/11/24 at 3:56 p.m., Staff #10 stated that the actuator for the screen door broke some time.. Based on observation, interview, and record review, the residence failed to ensure each staff member received orientation and training prior to providing any care services to a resident for one sample staff (#1), affecting 116 current residents. (Cross-reference S1410)Findings include: On 12/11/24 at 2:00 p.m., Staff #1 arrived at the residence to work in the secure environment (SE).A personnel file for Staff #1 read that the residence hired her on 6/1/19. The file contained no documentation that the staff member completed an orientation, including all required topics such as reporting requirements, occurrence reporting procedures, or resident rights.The November 2024 staff .. Based on observation, interview, and record review, the residence failed to investigate an allegation of abuse in accordance with the residence' s written policy, affecting 116 current residents. (Cross-reference S640)Findings include:1. Residence PolicyThe residence' s Resident Abuse Prevention policy, dated 8/8/17, read in part that the residence investigated all allegations of abuse and that the residence followed up on each allegation with documented interventions to prevent reoccurrence and assure the protection of all residents. 2. Record ReviewDocumentation of an investigation of abuse, dated 10/5/23, read that an external service provider (ESP) for Resident #2 noticed a bruis.. Based on observation, interview, and record review, the residence failed to update the enhanced care plan to include the necessary individualized staff approaches to address the resident' s behavioral expressions, affecting one of six sample residents (#9). (Cross-reference S3060)Specifically, Resident #9 had a diagnosis of dysphagia and had a risk of choking. Resident #9 ate a styrofoam holiday decoration two weeks before the onsite visit. Subsequently, the residence failed to update the care plan to include behavioral expressions with staff approaches to address the behavior. On 12/10/24, Resident #9 ate fake plastic snow. The residence failed to completely remove the plastic sno..

A licensure complaint, prompted by #CO28557 and #CO31603 was completed on 4/24/23. Deficiencies were cited. Based on interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of four sample residents (#1).Findings include:1. Resident #1 was admitted to the residence on 11/21/22 with diagnoses including hypothyroidism. a. LevothyroxineA written practitioner order, dated 11/19/22, directed the residence to administer levothyroxine 50 mcg once daily. However, the March 2023 medication administration record (MAR) read the medication was not administered on 3/25 and 3/27/23, for a total of two missed doses due to the medication being out of stock.b. PantoprazoleA written practitioner order, dated 11/19/22, directed the residence to administer pantoprazole sodium 40 mg once daily. However, the April 2023 MAR read the medication was not administered on 4/14/23, for a total of one missed dose due to the medication being out of stock.c. AcetaminophenA written practitioner order, dated 11/19/22, directed th.. Based on interview and record review, the residence failed to ensure the resident' s legal representative was promptly notified of a pattern of refusals, affecting one of four sample residents (#1). Findings include:1. Resident #1 was admitted to the residence on 11/21/22 with diagnoses including hypothyroidism. A written practitioner order, dated 2/21/23, directed the residence to administer Aspercreme three times daily. However, the April 2023 medication administration record read the medication was refused at 8:00 a.m. on 4/8, 4/10, 4/19/23 and at 1:45 p.m. on 4/10, 4/12, and 4/17-4/21/23, for a total of 10 refused doses.On 4/24/23 at 2:47 p.m., the legal representative for Resident #1 stated the residence had not contacted her to inform her that Resident #1 had a pattern of refusals.On 4/24/23 at 3:10 p.m., the health and wellness director stated a pattern of refusals was defined as three missed doses in a row. She stated staff should have notified the legal representative if the resident refused several doses of the m.. Based on interview and record review, the residence failed to have a roster of current residents that included their emergency contact information, along with a residence diagram showing room locations, affecting 103 current residents. Findings include:On 4/24/23 at approximately 1:00 p.m. the resident roster was requested and provided. However, the resident roster did not include the residents' emergency contact information, along with a residence diagram showing room locations.On 4/11/23 at approximately 3:26 p.m., the administrator stated she was not aware that residents' emergency contact information or a residence diagram showing room locations was required to be included with the resident roster. She stated that when emergency services entered the residence, she provided them with each resident' s face sheet.