Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bear Creek Senior Living during CMS and state inspections, most recent first.
Surveyors identified multiple infection control deficiencies, including improper hand hygiene, PPE use, and room disinfection. An RN administered a subcutaneous injection to a resident without performing hand hygiene between handling the med cart and the injection and did so without gloves, then later administered an oral medication that had fallen onto the med cart surface. During tracheostomy care for a resident, the same RN did not change gloves between removing a soiled inner cannula and inserting a clean one and did not use a gown or mask. In a separate observation, two CNAs and an RN provided high-contact care, including dressing, transferring, toileting, and wound care, to a resident with a Foley catheter and a buttock wound while only wearing gloves and not donning EBP gowns. Housekeeping staff were also observed spraying disinfectants on toilets, sinks, grab bars, and bedside tables and immediately wiping them dry, failing to meet required chemical dwell times and not fully disinfecting high-touch surfaces.
A facility failed to provide a written discharge notice to a resident, their representative, and the State LTC Ombudsman, as required. The resident, who had multiple medical conditions and was cognitively intact, was not readmitted after hospitalization due to the facility's claim of inability to meet their needs. The resident's representative was verbally informed but did not receive a written notice or information on appeal rights, leaving them unaware of how to appeal the discharge.
A facility failed to allow a resident to return after hospitalization, citing medication refusals as the reason. The resident, who had multiple medical conditions and was cognitively intact, was not provided with a discharge letter or appeal rights, violating facility policy. The decision was made by the IDT, but lacked proper documentation and communication with the resident's representative.
The facility failed to maintain an effective infection control program by not adequately monitoring water temperatures to prevent Legionella growth and not offering the COVID-19 vaccine to a resident. Water temperatures were often within the favorable range for Legionella, and there was no immediate follow-up monitoring. Additionally, a resident over 65 was not offered the COVID-19 vaccine, and their vaccination status was not documented, indicating lapses in the facility's vaccination tracking process.
Three residents in the facility experienced significant medication errors. One resident did not receive prescribed antibiotics for a UTI and an inhaler for COPD due to unavailability and lack of physician notification. Another resident missed doses of a nasal spray, and a third resident did not receive pain medication, with no documentation of physician notification. The facility's medication dispensing machine was not effectively used to prevent these errors.
A facility failed to ensure a resident with COPD had a clear physician's order for oxygen therapy, leading to confusion about whether the oxygen was to be used continuously or intermittently. Staff interviews revealed uncertainty about the resident's oxygen needs, and the deficiency was noted during a survey when it was found that the order had not been clarified.
A facility failed to offer a pneumococcal vaccine to a resident over 65 with no cognitive impairment. The resident's EMR lacked documentation of prior vaccinations, and staff interviews revealed that the ADON and DON missed reviewing the resident's immunization history upon admission. The facility did not have a comprehensive system to track and document resident immunization information, leading to this oversight.
Infection Control, EBP, and Environmental Disinfection Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper hand hygiene, appropriate use of PPE, hygienic room cleaning, and adherence to chemical dwell times. Facility policies stated that hand hygiene is the primary means to prevent spread of healthcare-associated infections and is required before resident contact, before aseptic tasks, after contact with blood or body fluids, after touching a resident or their environment, and immediately after glove removal. Despite this, a registered nurse (RN) prepared and administered a subcutaneous enoxaparin injection to a resident without performing hand hygiene between handling the medication cart and administering the injection, and without donning gloves while breaking the resident’s skin. The RN only performed hand hygiene after exiting the room and after touching the medication cart computer. In another instance, while preparing famotidine for a different resident, the RN allowed a tablet that had fallen onto the top of the medication cart to be administered to the resident instead of discarding it. Additional hand hygiene and aseptic technique failures were observed during tracheostomy care for a resident with a tracheostomy. The RN performed hand hygiene and donned clean gloves, but did not change gloves after removing the old inner tracheostomy cannula and before inserting the clean inner cannula. In interviews, the RN stated he did not know whether gloves were required for subcutaneous or intramuscular injections and reported he typically only wore gloves when manipulating an IV catheter. He also stated he did not know whether gloves should be changed between handling the soiled inner tracheostomy cannula and inserting the clean cannula, and that he had never considered the risk. The DON confirmed that hand hygiene should occur before dispensing and administering medications and after exiting the room, that gloves should be worn when breaking the skin for injections, that dropped pills should be discarded rather than administered, and that gloves should be changed after working with a dirty area such as a used tracheostomy cannula before moving to a clean area. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices and wounds during high-contact care activities. A resident with a tracheostomy reported that staff performing tracheostomy care wore gloves but never wore a yellow gown. During observed tracheostomy care for this resident, the RN performed hand hygiene and donned gloves but did not don a mask or yellow isolation gown, despite facility policy and CDC guidance indicating gown and gloves for device care such as tracheostomy care. In another observation, two CNAs and an RN provided high-contact care to a resident with a Foley catheter and a wound on the buttocks, including dressing, transferring with a sit-to-stand device, toileting, cleaning the resident’s bottom, and applying cream to the wound. They wore gloves but did not don EBP such as gowns during these high-contact activities. In interviews, a CNA stated she did not know of any special precautions for residents with tracheostomies, believed no residents were on EBP, and did not think special PPE was needed for dressing or toileting such residents. The RN involved in tracheostomy care stated he did not know what EBP were. The infection preventionist stated that residents with indwelling lines or skin breakdown that increased infection risk would qualify for EBP and that EBP had been implemented in the past, but signage had been replaced during COVID-19 outbreaks and not brought back. The DON stated that residents with additional lines such as catheters or tracheostomies or skin breakdown would be expected to be on EBP and that there were several residents on EBP, but she was unclear about whether transferring required gowns under EBP. She also noted that EBP orders should be in place and care planned, and that door signs sometimes get switched and not replaced. The facility further failed to follow manufacturer-recommended dwell times for disinfectant chemicals and to properly disinfect high-touch surfaces in resident rooms. Product information for NABC Concentrate required surfaces to remain wet for ten minutes, and Clean by 4D required treated surfaces to remain wet for a specified period for sanitization. Facility policy required following manufacturers’ instructions and cleaning horizontal surfaces daily and personal-use items at least twice weekly with disinfectant solution. During observations of two housekeepers cleaning resident rooms, both sprayed NABC Concentrate on toilets, sinks, counters, grab bars, and other bathroom surfaces and immediately wiped them dry, rather than allowing the required contact time. One housekeeper sprayed a rag with NABC to wipe a bedside table and used Clean by 4D on a grab bar, and the other used Clean by 4D on a side table, but in all instances the products were wiped off immediately. In interviews, the environmental services director stated that the dwell time for Clean by 4D was two minutes and for NABC Concentrate was ten minutes, and that housekeepers were trained to spray surfaces first and let the chemicals sit while they completed other tasks such as trash removal and sweeping. She acknowledged that staff sometimes get in a hurry. She also stated that high-touch surfaces expected to be disinfected included light switches, door knobs, doors around the knobs, furniture and handles, bedside tables and legs, lamps, call lights, and chair arms. The infection preventionist stated that high-touch surfaces such as remotes, call lights, bedside tables, door knobs, phones, and bed rails should be sanitized daily and that chemical dwell times should be followed to clean off the spread of germs.
Failure to Provide Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide a written discharge notice to a resident, their representative, and the State Long-Term Care Ombudsman at least 30 days before the resident's discharge. The facility did not issue a written notice that included the reason for the discharge, the effective date, the location to which the resident was being transferred, and the resident's appeal rights. Additionally, the facility did not send a copy of the discharge notice to the ombudsman, as required by their policy. The resident involved was over 65 years old and had multiple medical conditions, including alcoholic cirrhosis of the liver, type 2 diabetes with complications, and major depressive disorder, among others. The resident was cognitively intact and required supervision for most activities of daily living. Despite these needs, the facility decided not to readmit the resident after a hospitalization, citing an inability to meet the resident's needs and the resident's refusal to allow interventions for safety. Interviews revealed that the resident's representative was verbally informed of the discharge decision but did not receive a written notice or information on appeal rights. The facility's failure to document the discharge notice and notify the ombudsman was confirmed by the assistant director of nursing. The lack of proper documentation and notification led to the resident and their representative being unaware of the appeal process, which they expressed a desire to pursue.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, which was a violation of their policy regarding facility-initiated transfers and discharges. The policy states that residents who are sent to an acute care setting, such as a hospital, are expected to return to the facility unless specific criteria are met. In this case, the facility did not allow the resident to return, citing an inability to meet her needs due to her refusal to take medications, which was not aligned with the policy requirements for discharge. The resident in question was over 65 years old and had multiple medical conditions, including alcoholic cirrhosis of the liver, type 2 diabetes with complications, and major depressive disorder, among others. She was cognitively intact and required supervision for most activities of daily living. The resident had a history of refusing medications, which led to a change in her mental status and subsequent hospitalization. Despite this, the facility's policy required that residents be allowed to return unless their needs could not be met or the health and safety of others were at risk, which was not adequately documented in this case. Interviews with facility staff revealed that the decision to not allow the resident's return was made by the interdisciplinary team due to her medication refusals. However, there was no documentation of a facility-initiated discharge letter or notification of appeal rights provided to the resident or her representative. This lack of communication and documentation further contributed to the deficiency, as the resident's representative was not given the opportunity to appeal the decision, which is a requirement under the facility's policy.
Infection Control and Vaccination Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in monitoring water for Legionella and offering COVID-19 vaccinations to residents. The facility did not ensure that water temperatures were maintained outside the favorable range for Legionella growth, which is between 77 to 113 degrees Fahrenheit. The maintenance director (MTD) was unaware that the hot water temperatures did not meet the required control measure temperature for hot water storage or supply, which should be between 130 to 135 degrees Fahrenheit without a thermostatic mixing valve. The water temperature logs showed several instances where the temperatures were within the favorable range for Legionella growth, and there was no additional monitoring until the annual water analysis was completed. The facility's water management program was not effectively implemented, as the infection preventionist (IP) was not a member of the water management team, and there was no immediate follow-up monitoring when water temperatures were out of range. The director of nursing (DON) acknowledged that the water temperatures were not always in the range to prevent Legionella growth and that waiting for laboratory analysis could delay necessary follow-up actions. The facility's policy required weekly checks of cold water temperatures and annual Legionella culture tests, but the records indicated that these measures were not consistently followed. Additionally, the facility failed to offer the COVID-19 vaccine to a resident who was admitted over the age of 65. The resident's electronic medical record (EMR) did not indicate whether they had received any COVID-19 vaccinations prior to admission, and there was no documentation that the resident was educated, offered, or refused the vaccine since their admission. The assistant director of nursing (ADON) and the DON shared the responsibility of tracking resident vaccination status, but they were unable to find documentation regarding the resident's COVID-19 vaccination status, indicating a lapse in the facility's vaccination tracking and documentation process.
Medication Errors Affect Three Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting three residents. Resident #18 did not receive the prescribed antibiotics for a urinary tract infection upon admission from the hospital. The initial order for Amoxicillin was not entered into the computerized physician orders, resulting in the resident missing seven doses over several days. Additionally, the resident's inhaler for COPD was not available for administration for multiple days, and there was no documentation indicating that the physician was notified of these missed doses. Resident #6 experienced a lack of availability of a prescribed nasal spray, which was intended to relieve respiratory symptoms. The resident reported feeling miserable without the medication, and there was no documentation of the physician being notified about the unavailability of the nasal spray. The medication was noted as being on order from the pharmacy, but there was no follow-up documented to determine when it would be delivered. Resident #188 did not receive prescribed pain medication due to its unavailability. The resident missed multiple doses over several days, and there was no documentation that the physician was informed of these missed doses. The facility's automated medication dispensing machine, which could have been used to access urgent medications, was not utilized effectively to prevent these medication errors.
Deficiency in Oxygen Therapy Documentation
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had a clear and specific physician's order regarding the use of supplemental oxygen. The deficiency was identified for a resident with chronic obstructive pulmonary disorder (COPD), who was observed using an oxygen concentrator set at 2 liters per minute (LPM) but reported only using oxygen at night. The physician's order did not specify whether the oxygen was to be used continuously or intermittently, leading to confusion about the resident's oxygen therapy needs. Interviews with staff, including a registered nurse and the director of nursing, revealed that the physician's order lacked documentation on the specific use of oxygen, and there was uncertainty about whether the resident required continuous oxygen. The facility's oxygen care plan indicated continuous use, but this was not reflected in the physician's order. The deficiency was noted during a survey when it was discovered that the order had not been clarified, resulting in a lack of adherence to professional standards of practice for oxygen therapy.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to develop and implement policies and procedures related to pneumococcal vaccines for one of the residents reviewed for vaccinations. Specifically, the facility did not ensure that a resident, who was over the age of 65 and had no cognitive impairment, was offered the pneumococcal vaccine. The resident's electronic medical record did not indicate whether she had received any pneumococcal vaccinations prior to her admission to the facility, and there was no documentation that she was offered the vaccine upon admission. Interviews with the assistant director of nursing (ADON) and the director of nursing (DON) revealed that they shared the responsibility of tracking resident vaccination status. However, they admitted to missing the review of the resident's immunization history upon admission, which led to the oversight. The ADON stated that the facility did not have a system in place to track and document resident immunization information comprehensively, which contributed to the failure to offer the pneumococcal vaccine to the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brookdale Skyline | 0.7 mi | ★★★★★ | 1 | 0 |
| Sundance Skilled Nursing And Rehabilitation | 0.9 mi | ★★★★★ | 22 | 1 |
| Kiowa Hills Rehabilitation And Nursing, Llc | 1.1 mi | ★★★★★ | 8 | 0 |
| Gardens, The | 1.8 mi | ★★★★★ | 12 | 0 |
| The Healthcare Resort Of Colorado Springs | 2.5 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.