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 August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Forest Ridge Health And Rehab Llc during CMS and state inspections, most recent first.
The facility failed to ensure meals were consistently palatable and properly prepared, resulting in multiple residents receiving food that was cold, bland, overcooked, undercooked, or of poor texture. Residents and their representatives reported ongoing issues such as runny eggs, burned toast, watery soup, mushy vegetables, undercooked potatoes, tough meats, cold french fries, missing condiments, incorrect meal items, and delayed meal service. A test tray sampled by surveyors showed entrée items at low temperatures and dry, firm pasta, with missing butter for a roll. Resident council records documented repeated complaints about cold food and poor food quality, while hot carts intended to address temperature issues remained unused in their boxes. Staff interviews confirmed awareness of complaints about chewy meats and runny eggs, and revealed that the cook had limited LTC experience and found specialized diet textures challenging, contributing to the facility’s failure to provide consistently palatable meals.
Housekeeping staff failed to follow infection control practices while cleaning resident rooms. One housekeeper repeatedly changed gloves without performing hand hygiene, immediately wiped or rinsed surfaces after applying Waxie 730 HP instead of allowing the required dwell time, and did not disinfect all high-touch surfaces. Another housekeeper also failed to perform hand hygiene after glove removal and before donning clean gloves, and continued cleaning after toilet care without changing gloves. The DON, IP, and environmental services supervisor stated that hand hygiene was required after glove removal and when moving between dirty and clean tasks, and that the disinfectant needed proper dwell time to work.
Failure to Protect a Resident from Sexual Abuse: A resident with severe dementia and no capacity to consent was sexually touched by another resident with severe dementia and a history of escalating affectionate behavior toward female residents. Staff witnessed the contact in the hallway, the facility substantiated sexual abuse, and interviews showed repeated prior boundary issues, redirection attempts, and uncertainty about whether cognitively impaired female residents could truly consent.
A resident with mood disorder, anxiety, vascular dementia, and depression was prescribed sertraline, but the EMR had no documentation of behavior monitoring, side effect monitoring, or effectiveness monitoring. Staff reported the resident yelled out, moved tables, hit staff, and slept most of the time, yet the resident was not added to the alert charting binder and had no care plan for psychotropic monitoring.
Expired and unlabeled medications were found in medication carts and a medication storage room. Surveyors observed a hospice emergency kit with five expired meds, expired Pro-Stat, expired vitamin B12, and expired sunscreen, and also found latanoprost without an open date and a budesonide/formoterol inhaler with an open date that did not match when it was already open. An LPN said expired meds would be disposed of, and the DON said night shift nurses audited carts for expired meds.
A resident with dementia and other medical conditions experienced severe weight loss due to the facility's failure to provide adequate nutrition. Despite recommendations from the RD for large meal portions, the resident continued to receive regular portions and was not offered additional food. Observations showed the resident consumed all meals and displayed signs of hunger, yet the facility did not implement necessary dietary changes. Staff interviews revealed communication lapses and system issues that contributed to the oversight.
The facility failed to maintain sanitary conditions in the kitchen by not consistently monitoring refrigerator and freezer temperatures and lacking a system to verify the dishwasher's internal temperature. Dietary staff were not adequately trained on these procedures, leading to incomplete temperature logs and potential sanitation issues.
The facility failed to maintain an effective infection control program, as an LPN did not follow proper wound care techniques, mixing clean and dirty supplies without performing hand hygiene. Additionally, the facility lacked an active Legionella water management plan, with no documentation of monitoring or testing. The NHA acknowledged the absence of the program, which was identified as a need during a recent QAPI meeting.
The facility failed to assess and obtain consent for bed rail use for eight residents, leading to deficiencies in safety evaluations, informed consent, and physician's orders. Residents had bed rails installed without proper assessments, and the facility did not conduct routine inspections for potential entrapment risks. Staff interviews revealed a lack of adherence to policies regarding bed rail use.
The facility failed to properly store and label medications, with Tuberculin PPD vials not dated after opening and past their usage period. Medications were stored alongside food items in unit medication refrigerators, violating sanitary practices. Staff interviews confirmed these practices were against facility policy.
The facility failed to ensure adequate supervision to prevent falls for two residents. The facility did not identify the root cause of falls, implement timely interventions, or update care plans after each fall. Both residents experienced multiple falls without timely or effective interventions being added to their care plans.
Failure to Provide Palatable, Properly Prepared and Temperature-Controlled Meals
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents consistently received palatable food with acceptable taste, texture, and temperature, as required by its own policy. The facility’s Standardized Menus policy stated that residents would receive nourishing, palatable meals to meet nutritional needs and that menus would be planned to be appetizing and culturally appropriate. However, the policy lacked specific procedures or quality control measures to ensure food was served at acceptable taste, texture, and temperature, and did not address prevention of overcooking, undercooking, dryness, or burned food items, nor did it include a process to assess meal palatability prior to service. Multiple resident representatives and residents reported ongoing concerns about food quality, including temperature, taste, and texture. One resident representative stated that food issues had been ongoing and discussed in resident group meetings, with some recent improvement but persistent problems such as runny eggs. Another representative reported that food was often cold, ice cream was soupy, and that a resident was not awakened for breakfast and instead received cereal with milk much later than her usual meal time, disrupting her normal meal pattern. The same representative later described watery potato soup, mushy broccoli, an undercooked hard baked potato, cold french fries, and tough meats such as beef, noting that the resident sometimes ate at her daughter’s home and that she felt guilty leaving the resident at the facility. In a resident group interview with seven alert and oriented residents, participants reported that food was served cold, pork was impossible to chew, other meats were tough, and meal delivery took hours despite having reported these concerns to facility leadership. Individual resident interviews further detailed that eggs were served runny with excess moisture, food lacked taste and was lukewarm, meals were bland, and requested items such as cheeseburgers and condiments were either incorrect, delayed, or missing. One resident reported that pork was served in strings, french fries were not crisp and were cold, and that she felt the facility did not care about residents. Another resident stated the food was horrible, did not taste good, and that when she voiced concerns to the dietary manager and operations manager, she was told the food was as good as it was going to get, leading her to obtain her own sliced meat and cheese multiple times per week. Direct observations by surveyors corroborated these complaints. One resident’s breakfast tray contained toast that was burned on both sides and very hard to chew, which the resident could not eat, and scrambled eggs that were very moist and slightly wet, with a napkin saturated from absorbing excess moisture; the resident stated she had repeatedly reported runny eggs to the dietary manager without resolution. Another resident was observed eating only oranges for breakfast and stated she did not like the facility’s scrambled eggs, describing them as fake, and preferred eggs at her daughter’s house. A test tray evaluated by four surveyors showed that shrimp over pasta was served at approximately 106°F, tasted cool or cold on the palate, the pasta was dry and slightly firm, and no butter was provided for the dinner roll. Record review showed that resident council meeting minutes and grievance forms documented repeated dietary concerns, including cold food and food quality issues, and referenced hot carts and meal covers being ordered to address temperature concerns. However, during the survey, hot carts were observed still in their delivery boxes outside the main entrance and had not been implemented. Staff interviews revealed that the dietary manager acknowledged complaints about overcooked and chewy meats and stated she did not know what could be done to make meat tender. She also stated that eggs should not have been runny but could not explain why runny eggs were served. The cook, who had prior restaurant and baking experience but no prior hospital or nursing home cooking experience, identified challenges in meeting different dietary textures and expressed surprise about burned toast and runny eggs, stating she cooked eggs thoroughly. The DON reported that staff were expected to monitor meal tickets and check food temperatures before trays left the kitchen and again on the floor, and that unpalatable food should be returned for replacement, but the repeated resident complaints and surveyor observations demonstrated that residents continued to receive food that was not consistently palatable in taste, texture, or temperature.
Failure to Follow Hand Hygiene and Disinfection Dwell Time During Room Cleaning
Penalty
Summary
The facility failed to maintain its infection control program during housekeeping activities in resident rooms. During a continuous observation, Housekeeper #2 cleaned a resident shower, bedroom, and bathroom while repeatedly changing gloves without performing hand hygiene before donning new gloves or after removing used gloves. Housekeeper #2 also used Waxie 730 HP disinfectant cleaner on the shower, sink, toilet, grab bar, wall, counter, and toilet surfaces, but immediately rinsed, wiped, or dried those surfaces instead of allowing the disinfectant to remain in place for the required dwell time. In addition, high-touch surfaces in two resident rooms were not disinfected. During another continuous observation, Housekeeper #1 cleaned resident rooms and also failed to perform hand hygiene after removing gloves and exiting rooms, and before putting on clean gloves when moving between rooms. Housekeeper #1 wiped high-touch surfaces in the bedroom and bathroom, scrubbed the toilet, and then continued sweeping and mopping the bedroom and bathroom without changing gloves after toilet cleaning. Housekeeper #1 also removed soiled gloves and exited rooms without performing hand hygiene. Facility staff interviews confirmed the expected practices. The environmental services supervisor stated the disinfectant dwell time was three to four minutes, that high-touch surfaces should be cleaned daily, that gloves should be changed with every new task such as moving from the bedroom to the bathroom, and that hand hygiene should be completed after glove removal. The IP, ADON, and DON all stated that hand hygiene should be performed when entering and exiting resident rooms, after glove removal, and when moving from dirty to clean tasks, and that following chemical dwell times was important so the product had time to disinfect surfaces.
Failure to Protect a Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to ensure a resident was free from sexual abuse when one resident sexually touched another resident in the hallway. Staff witnessed the two residents walking toward each other, with one resident giving the other a hug. As the resident was walking away, the other resident grabbed her buttocks and slid his hand down to her crotch. The facility investigation substantiated the allegation of sexual abuse, and the resident who initiated the contact was placed on one-to-one staff supervision after the incident. The resident who was touched was an older adult with Pick’s disease dementia and Alzheimer’s disease. Her MDS showed severe cognitive impairment, no BIMS was conducted, and she required assistance with toileting, showering, dressing, oral hygiene, and eating. Her care plan, initiated after the incident, identified that she lacked the capacity to consent to sexual intimacy because of severe cognitive impairment and that she was at risk for misunderstanding interpersonal boundaries, exploitation, or emotional and physical harm. However, the care plan did not include interventions to keep her safe from another recurrence related to her lack of capacity to consent. The resident who initiated the contact was an older adult with severe vascular dementia, a history of TIA and cerebral infarction, disorientation, and PTSD. His MDS also showed severe cognitive impairment. His behavior care plan identified a history of affectionate behavior with female residents related to cognitive impairment and included redirection and supervision interventions, but staff documented repeated incidents of increased interest in female residents over the weeks before the event, including holding hands, kissing, rubbing a female resident’s knee, and going into female residents’ rooms. Staff interviews confirmed that his behavior escalated despite repeated redirection, and staff stated it was difficult to determine whether contact with cognitively impaired female residents was consensual.
Failure to Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure one resident was free from unnecessary psychotropic medication use because there was no documented monitoring of behaviors, side effects, or medication effectiveness for a prescribed antidepressant. Resident #9, who had diagnoses including unspecified mood disorder, anxiety disorder, vascular dementia, and depression, was assessed as having severe cognitive impairment, short- and long-term memory problems, and needing maximal assistance with most ADLs. The resident had a physician order for sertraline 25 mg daily starting 1/14/26. Record review showed no documentation in the EMR related to behavior monitoring, side effect monitoring, or effectiveness monitoring for the sertraline. There was also no care plan for behavior monitoring or side effect monitoring related to the antidepressant. Staff interviews indicated the resident yelled out for help, moved tables in the dining room, and hit staff, and that he slept most of the time and became angry when awakened. The CNA said he was unaware the resident had been started on an antidepressant, and the LPN said the resident was supposed to be added to the alert charting binder but was not. The DON stated psychotropic medications should have a care plan identifying behaviors and side effects to monitor and that effectiveness was monitored through behavior charting.
Expired and Unlabeled Medications Found in Storage Areas
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles and stored properly in locked medication areas. Surveyors found expired medications in two medication carts and one medication storage room, including a hospice emergency kit with five medications all expired on 12/24/25, a bottle of Pro-Stat expired on 5/21/25, a bottle of vitamin B12 expired in January 2026, and a bottle of sunscreen expired in May 2021. The facility also failed to ensure medications were labeled with the date they were opened. During observation of the Pine medication cart, latanoprost ophthalmic solution was not labeled with an open date, and budesonide/formoterol inhaler had an open date of 3/1/26 even though the medication was already open. LPN #2 stated she would dispose of the expired medications and said the night shift nurses were responsible for disposing of expired medications. The DON stated the night shift nurses audited the medication carts on Sunday nights for expired medications and said it was important to keep medication storage areas free from expired and mislabeled medications so residents received the correct strength of medication and nurses were aware of shortened expiration dates such as for eye drops.
Failure to Provide Adequate Nutrition Leads to Severe Weight Loss
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to meet their nutritional needs, resulting in severe weight loss. The resident, who was admitted for long-term care with diagnoses including dementia, abdominal pain, and vascular disorder of the intestine, experienced significant weight loss over several months. Despite recommendations from the registered dietitian (RD) to provide large portions at meals, the resident did not receive these portions and was not offered additional food when they consumed 100% of their meal. Observations revealed that the resident was served regular diet portions and consumed all of their meals, indicating a need for more food. The resident displayed behaviors such as licking their plate and attempting to eat from an empty plate, suggesting hunger. Despite these signs, the facility did not implement person-centered nutritional interventions to address the resident's severe weight loss. The resident's care plan and electronic medical record did not reflect the RD's recommendation for large portions, and the facility's staff failed to follow through with the necessary dietary changes. Interviews with facility staff, including CNAs, LPNs, and the ADON, highlighted a lack of communication and follow-up regarding the resident's nutritional needs. The facility's switch in electronic systems and the absence of a dietary manager at times contributed to the oversight in providing the resident with the appropriate diet. The facility's failure to implement timely and effective nutritional interventions resulted in the resident's continued severe weight loss, despite the RD's recommendations and the resident's evident need for additional nutrition.
Deficiency in Kitchen Sanitation Practices
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen, specifically in the storage, preparation, distribution, and serving of food. Observations revealed that the facility did not consistently monitor the temperatures of refrigerators and freezers, with 21 out of 46 opportunities to record temperatures being missed. Additionally, the facility lacked a system to monitor the internal temperature of the dishwasher, which is crucial for ensuring proper sanitization of utensils. Dietary aides were unaware of how to verify the internal temperature of the dishwasher, and there was no temperature log maintained for the dishwasher cycles. Interviews with dietary staff and the dietary manager highlighted a lack of training and adherence to facility policies regarding temperature monitoring. The dietary aides were not adequately informed about the procedures for operating the new dishwashing machine and maintaining temperature logs. The dietary manager acknowledged the necessity of monitoring temperatures to prevent bacterial growth and ensure proper sanitation but noted that the temperature logs for the dishwasher and the main kitchen's walk-in refrigerator and freezer were incomplete or missing.
Infection Control Deficiencies in Wound Care and Legionella Management
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by improper wound care techniques and the absence of a Legionella water management plan. During an observation, an LPN did not follow the facility's wound care policy, which required establishing a clean field and performing hand hygiene. Instead, the LPN placed clean supplies on a trash bag on the resident's bed, mixed clean and dirty items, and failed to change gloves or wash hands after handling soiled dressings. This improper technique was acknowledged by both the LPN and the DON, who confirmed that the clean field was not maintained and that hand hygiene was not performed as required. Additionally, the facility did not have an active Legionella water management program in place, which is crucial for preventing the growth and spread of Legionella bacteria in the water system. The facility's policy required a water management team to oversee this program, but there was no documentation of monitoring or testing for Legionella. Interviews with the IP and ESD revealed a lack of awareness and involvement in the water management program, and the ESD admitted to not having documentation of water monitoring or testing. The NHA, who was new to the facility, acknowledged the absence of a Legionella water management program and stated that it was identified as a need during a recent QAPI meeting. The facility was in the process of implementing a program based on CDC guidelines, but at the time of the survey, no active program was in place to prevent Legionella within the facility.
Failure to Assess and Obtain Consent for Bed Rail Use
Penalty
Summary
The facility failed to use a person-centered approach in determining the use of bed rails for eight residents. The deficiencies included not assessing residents for the risk of entrapment before installing bed rails, not obtaining informed consent from residents or their representatives, and not acquiring physician's orders for the use of bed rails. Additionally, the facility did not conduct quarterly assessments to evaluate the continued need and safety of the bed rails. For Resident #1, the facility did not perform a bed rail evaluation or obtain consent before the installation of bed rails, despite the resident being cognitively intact and dependent on staff for mobility. The resident's electronic medical record lacked documentation of quarterly assessments for the bed rails' continued use and safety. Similarly, Resident #33 had a bed rail installed without a physician's order, evaluation, or consent, and the resident was unaware of the reason for its presence. Other residents, such as Resident #36 and Resident #44, also had bed rails installed without proper evaluations, consent, or physician's orders. The facility's maintenance department failed to conduct routine inspections of the bed rails to identify potential entrapment risks. Interviews with staff, including CNAs and LPNs, revealed a lack of awareness and adherence to the facility's policies and procedures regarding bed rail use, further contributing to the deficiencies.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored and labeled according to professional standards on two of its four units. Specifically, the facility did not date Tuberculin purified protein derivative (PPD) vials after opening, and one vial was found to be past its 30-day usage period. This oversight was observed during a survey of unit medication refrigerators, where a vial of Tubersol PPD was found opened and undated, and another vial was dated as opened on 4/12/24, which should have been discarded by 5/12/24. Additionally, the facility did not maintain a sanitary separation between refrigerated medications and food items. Observations revealed that unit medication refrigerators contained several unopened nutritional supplement drinks, soda drinks, yogurt, pudding cups, and an opened med pass shake stored alongside medications such as Bisacodyl suppositories, eye drops, and probiotic containers. Interviews with staff, including a registered nurse and the assistant director of nursing, confirmed that storing food items with medications was not a sanitary practice, and the facility's policy required medications to be stored separately from food.
Failure to Prevent Falls and Update Care Plans
Penalty
Summary
The facility failed to ensure residents received adequate supervision to prevent accidents for two residents reviewed for falls. Specifically, the facility did not identify the root cause of falls and implement timely and effective interventions to prevent further falls. Additionally, the facility did not update and revise the residents' care plans with new interventions after each fall, as required by their policy. Resident #68, who had severe cognitive impairment and was at high risk for falls, experienced multiple falls. The facility did not conduct a root cause analysis for the falls on 4/13/24 and 5/16/24, and new interventions were not added to the resident's care plan in a timely manner. The resident's fall care plan was not updated with new interventions after each fall, and the interdisciplinary team did not identify the root cause of the falls. Resident #70, who had a history of falls and severe cognitive impairment, also experienced multiple falls. The facility failed to initiate a fall care plan with interventions to prevent falls until after the resident sustained a fall. The care plan did not specify how often frequent checks should be conducted, and new interventions were not documented or implemented in a timely manner after each fall. The interdisciplinary team did not identify the root cause of the falls, and the resident's fall care plan was not updated promptly after each incident.
What surveyors are citing around you — mapped
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What surveyors actually found near you
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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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Woodland Park
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mount St Francis Nursing Center | 10.9 mi | ★★★★★ | 0 | 0 |
| Gardens, The | 13.4 mi | ★★★★★ | 12 | 0 |
| Center At Centennial, The | 13.9 mi | ★★★★★ | 0 | 0 |
| The Healthcare Resort Of Colorado Springs | 14.3 mi | ★★★★★ | 0 | 0 |
| Sundance Skilled Nursing And Rehabilitation | 14.3 mi | ★★★★★ | 21 | 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 August 2026) and official state health department websites.