Stonecreek of Flying Horse

A licensure complaint, prompted by #CO41582 and #CO41629, was completed on 3/10/26. Deficiencies were cited. Based on Interview and record review, the residence failed to ensure the routine and prompt handling of grievances and complaints brought by residents and advocates. (Cross-Reference U540)Findings Include: 1. Residence policyThe residence' s undated grievance policy read "Complaints from residents, family members, or advocates are addressed promptly and effectively." 2. Observations On 3/10/26 at 10:28 a.m., Resident #8 shared seven pictures. On 1/6/26 and 1/16/26, the food was served burnt. 1/9/26 soup was served with very little to no broth. 3. Record reviewa. Resident council notes dated 12/11/25, read in part, Resident #10 had emailed the senior regional culinary director (SRCD) for a meeting about better food. Residents are encouraged to take pictures of their food and email if it is unsatisfactory. Residents are encouraged to fill out rating cards for food. The food was cold, hard, or burnt. Plating needs more presentation, and the food was getting worse. The claims listed online about the kitchen do not meet th.. Based on observation, record review, and interview, the administrator failed to be responsible for day-to-day operations that included reviewing marketing materials and information published by the assisted living residence (ALR) to ensure consistency with the services actually provided by the ALR. Affecting 90 current residents (Cross-reference U1400) Findings include:1. Record Reviewa. An electronic web-based marketing publication from the residence titled "Our delectable Colorado culinary program for seniors" read in part chef prepared meals are made with the finest ingredients and tailored to meet each resident' s dietary needs. Highest quality ingredients and a beautifully presented plate of food. Elevated dining experience by empowering them to make choices that reflect unique preferences, traditions, and family recipes, partnered with [Brand name] creamery to make sure sweet seasonal delights are available daily. We take pride in our dining program, operating at the same level as rest.. Based on record review and interview, the residence failed to update the care plan with the most current assessment information, affecting three of four sample residents (#1,#2, and #5). Findings Include: 1. Record Review Resident #5 was admitted to the residence on 8/16/25 with a diagnosis of Atherosclerotic Heart disease (ASHD), Dyspnea, Peripheral Vascular Disease (PVD), Macular degeneration, Hypertensive Chronic Kidney Disease with Stage 1 through Stage 4 Chronic Kidney Disease, or Unspecified ChronicKidney Disease, Peripheral Vascular Disease, Primary InsomniaA care plan dated 8/14/24 read in part that Resident #5 was "at risk for falls." A progress note for Resident #5, dated 1/14/26, read in part that Resident #5 had an unwitnessed fall on 1/14/25. Resident #5 had attempted to stand up from the toilet and missed the bar. He fell and hit his head. Emergency medical services (EMS) evaluated the resident.An assessment dated 1/14/26 read that the resident #5 had a change in condition that required more care n..

A revisit survey was completed on 12/9/25 for all previous deficiencies cited on 9/4/25. The facility is in compliance with all regulations surveyed. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A revisit survey was completed on 12/9/25 for all previous deficiencies cited on 9/4/25. The facility is in compliance with all regulations surveyed. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A complaint revisit was completed on 9/4/25 for all previous deficiencies cited on 9/18/24. Deficiencies were cited. Based on observation, record review, and interview, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary events, and failed to ensure that the resident records contained documentation of ongoing services provided by external service providers (ESP). Additionally, the residence failed to ensure that staff members had documented, before the end of their shift, events or issues regarding a resident that they observed or reported to them, affecting one of three sample residents. (#22) Findings include:Record ReviewsResident #22 was admitted to the residence on 5/5/25 with a diagnosis of senile degeneration of the brain. An incident report on 8/31/25 read in part that resident #22 had a fall and hit her face an.. Based on observations, record review, and interview, the residence failed to ensure that each staff member received training, such as training that includes the care and services provided by the residence, affecting 18 current secured environment (SE) residents. This deficient practice was previously cited; however, the residence had not maintained compliance. Findings Include:Resident #24 was admitted to the residence on 3/8/23, with diagnoses that included dementia.Resident #24' s care plan dated 7/23/25, read that the resident was on a mechanical diet and required feeding assistance. Additional notes in her care plan indicate that she required monitoring for chewing difficulties, hand-over-hand feeding assistance, and staff to remain present at all times. .. Based on record review and interview, the residence failed to comply with the authorized practitioner' s ordersassociated with medication administration except for those medications which a resident self-administers, affecting one of nine sample Residents (#21). This deficiency was cited previously during a state licensure survey 9/18/24. Although the facility corrected thedeficiency, based on the findings below, the facility has not maintained compliance with this regulatoryrequirement.Findings include:1. Record reviewResident #21 was admitted to the residence on 8/31/23, diagnoses included dementia and delusional disordersA written practitioners order, with a start date of 5/23/25, directed the residence to administer acetaminophen 325 mg tablets - take two tablets twice daily. .. Based on record review and interviews, the residence failed to make available, either directly or indirectly personal services, including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or ongoing monitoring affecting two of nine sample Resident' s (#21 and #22).Findings include:1. Record reviewResident #21 was admitted to the residence on 8/31/23, diagnoses included dementia, arthritis and hypertension. The care plan, with an effective date of 8/30/23, read in part: Staff will strip Resident #21' s bed every Thursday and put clean sheets on. A document titled Complaints and Concerns read in part: On 3/24/25 Resident #21 submitted a complaint regarding linen changes needing to occur when scheduled. The docu..

A licensure complaint, prompted by #CO38649, #CO39296, #CO39500 and #CO39579, was completed on 9/4/25. Deficiencies were cited. Based on observation, record review, and interview, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary events, and failed to ensure that the resident records contained documentation of ongoing services provided by external service providers (ESP). Additionally, the residence failed to ensure that staff members had documented, before the end of their shift, events or issues regarding a resident that they observed or reported to them, affecting one of three sample residents. (#22) Findings include:Record ReviewsResident #22 was admitted to the residence on 5/5/25 with a diagnosis of senile deg.. Based on observations, record review, and interview, the residence failed to ensure that each staff member received training, such as training that includes the care and services provided by the residence, affecting 18 current secured environment (SE) residents. This deficient practice was previously cited; however, the residence had not maintained compliance. Findings Include: Resident #24 was admitted to the residence on 3/8/23, with diagnoses that included dementia.Resident #24' s care plan dated 7/23/25, read that the resident was on a mechanical diet and required feeding assistance. Additional notes in her care plan indicate tha.. Based on record review and interview, the residence failed to comply with the authorized practitioner' s ordersassociated with medication administration except for those medications which a resident self-administers, affecting one of nine sample Residents (#21). This deficiency was cited previously during a state licensure survey 9/18/24. Although the facility corrected thedeficiency, based on the findings below, the facility has not maintained compliance with this regulatoryrequirement.Findings include:1. Record reviewResident #21 was admitted to the residence on 8/31/23, diagnoses included dementia and delusional disordersA written practitioners order, with a star.. Based on record review and interviews, the residence failed to make available, either directly or indirectly personal services, including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or ongoing monitoring affecting two of nine sample Resident' s (#21 and #22).Findings include:1. Record reviewResident #21 was admitted to the residence on 8/31/23, diagnoses included dementia, arthritis and hypertension. The care plan, with an effective date of 8/30/23, read in part: Staff will strip Resident #21' s bed every Thursday and put clean sheets on. A document titled Complaints and Concerns read in part:.. 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 7.12.17 The assisted living residence shall ensure that it has trained staff available to evaluate residents who have fallen or are otherwise unable to independently get up off the floor and provide lift assistance when determined appropriate instead of relying on emergency medical responders. (A) Each situation shall be evaluated to determine if the resident can be assisted in a safe manner such as when the resident has no pain and/or..

A complaint revisit was completed on 9/4/25 for all previous deficiencies cited on 9/18/24. Deficiencies were cited. Based on observation, record review, and interview, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary events, and failed to ensure that the resident records contained documentation of ongoing services provided by external service providers (ESP). Additionally, the residence failed to ensure that staff members had documented, before the end of their shift, events or issues regarding a resident that they observed or reported to them, affecting one of three sample residents. (#22) Findings include:Record ReviewsResident #22 was admitted to the residence on 5/5/25 with a diagnosis of senile deg.. Based on observations, record review, and interview, the residence failed to ensure that each staff member received training, such as training that includes the care and services provided by the residence, affecting 18 current secured environment (SE) residents. This deficient practice was previously cited; however, the residence had not maintained compliance. Findings Include:Resident #24 was admitted to the residence on 3/8/23, with diagnoses that included dementia.Resident #24' s care plan dated 7/23/25, read that the resident was on a mechanical diet and required feeding assistance. Additional notes in her care plan indicate that she required monitoring for chewing .. Based on record review and interview, the residence failed to comply with the authorized practitioner' s ordersassociated with medication administration except for those medications which a resident self-administers, affecting one of nine sample Residents (#21). This deficiency was cited previously during a state licensure survey 9/18/24. Although the facility corrected thedeficiency, based on the findings below, the facility has not maintained compliance with this regulatoryrequirement.Findings include:Record reviewResident #21 was admitted to the residence on 8/31/23, diagnoses included dementia and delusional disordersA written practitioners order, with a star.. Based on record review and interviews, the residence failed to make available, either directly or indirectly personal services, including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or ongoing monitoring affecting two of nine sample Resident' s (#21 and #22).Findings include:Record reviewResident #21 was admitted to the residence on 8/31/23, diagnoses included dementia, arthritis and hypertension. The care plan, with an effective date of 8/30/23, read in part: Staff will strip Resident #21' s bed every Thursday and put clean sheets on. A document titled Complaints and Concerns read in part:.. Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally