Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
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 Colonial Rehabilitation And Nursing, Llc during CMS and state inspections, most recent first.
The facility did not ensure required RN coverage for at least eight consecutive hours per day when no RN was scheduled on multiple days while the DON was on vacation, and the staffing schedule created by the scheduling coordinator lacked any RN coverage during that period.
A resident with a history of mental health disorders and aggressive behaviors verbally threatened and attempted to physically harm another resident in the dining room. Staff and other residents witnessed the incident, and the police were called. The victim, who had mild cognitive impairment and required assistance with daily activities, reported feeling scared and subsequently avoided the dining room. The facility did not have adequate interventions or monitoring in place to prevent the abuse, and triggers for the aggressive resident's behavior were not clearly documented until after the incident.
A resident with severe cognitive and physical impairments fell during a transfer when staff failed to fully extend the legs of a manual Hoyer lift, causing it to tip. Staff reported the manual lift was unstable and that concerns had been raised to management, but not all staff received training on its use. Electric Hoyer lifts were unavailable for a period due to battery issues, and communication about their operational status was inconsistent.
A resident did not receive treatment and care in accordance with physician orders and their own stated preferences and goals, resulting in a failure to follow the established care plan.
The facility did not ensure that an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
The facility failed to protect residents from various forms of abuse and neglect, including physical, mental, and sexual abuse, as well as physical punishment, by any individual.
Three residents did not receive or were not offered individualized activity programs as required by their care plans, including missed opportunities for pet therapy, group activities, and other preferred engagements. Documentation of activity offers and refusals was inconsistent, and staff did not always ensure residents were invited to participate in activities that matched their interests and needs.
Three residents were not provided with the least restrictive approaches for managing behaviors, as their care plans lacked resident-specific non-pharmacological interventions and consistent documentation of behaviors to justify ongoing psychotropic medication use. For one resident, required gradual dose reductions of psychotropic medications were not consistently attempted or properly documented, and physician rationales for contraindications were missing. Staff interviews revealed gaps in knowledge and documentation regarding effective non-pharmacological interventions.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet personal care needs.
A resident did not receive appropriate care for existing pressure ulcers, and the facility failed to implement effective measures to prevent new ulcers from developing. Observations and record reviews showed lapses in assessment, monitoring, and treatment, with protocols for pressure ulcer care not consistently followed.
A resident did not receive the necessary care or services to maintain or improve range of motion or mobility, and the facility did not ensure appropriate interventions were in place to prevent avoidable decline.
A deficiency was found due to the facility's failure to provide appropriate care for residents who are continent or incontinent of bowel/bladder, as well as inadequate catheter care and insufficient measures to prevent UTIs.
A resident was provided with a feeding tube without documented medical necessity or agreement, and did not receive appropriate care for the feeding tube.
A resident with dementia did not receive the necessary treatment and services to address their condition, resulting in a deficiency related to inadequate dementia care.
A deficiency was cited when a resident’s drug regimen included unnecessary medications, either due to lack of clinical indication, excessive dosing, or duplicative therapy, without proper documentation or justification.
A CNA was observed emptying a resident's catheter bag without wearing gloves or a gown, despite the resident being on enhanced barrier precautions (EBP). Staff interviews revealed a lack of training on catheter care, and facility leadership confirmed that proper PPE should have been used during this high-contact care activity.
The facility failed to ensure residents could choose their attending physician after a change in medical provider groups. Four residents were not properly informed of their rights or given adequate choices, and consent was not documented. Staff interviews revealed that the previous owner restricted physician choices, and the new ownership continued this practice by offering only two physicians without informing residents about insurance coverage.
Failure to Provide Required Daily RN Coverage
Penalty
Summary
The facility failed to ensure the services of a registered nurse (RN) were provided for at least eight consecutive hours per day, seven days a week, as required. Record review of the nursing staff schedules for 3/2/26, 3/3/26, and 3/4/26 showed that no RNs were scheduled to work on those three days. During an interview, the nursing home administrator confirmed that there were no RNs available in the facility on those dates while the director of nursing (DON) was on vacation and stated that the scheduling coordinator was responsible for creating the staffing schedule to ensure RN coverage for at least eight hours each day. No additional information was provided in the report regarding specific residents, their medical conditions, or any clinical events occurring during the period without RN coverage.
Failure to Protect Resident from Verbal Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident from verbal abuse by another resident, resulting in a substantiated incident of abuse. On the day of the incident, one resident with a history of bipolar disorder, anxiety disorder, and schizoaffective disorder became verbally aggressive and threatened another resident in the dining room. The aggressor raised his fist, attempted to strike the other resident with a chair, and continued to be verbally abusive to staff who intervened. Multiple staff members witnessed the event, and the police were called. The resident who was threatened reported feeling scared for his life and stated he would avoid the dining room due to repeated incidents. Prior to this event, the aggressive resident had a documented history of both verbal and physical aggression toward staff and other residents, including threats, yelling, and attempts to physically harm others. Care plans noted the potential for aggression, but triggers and interventions were not consistently identified or updated in a timely manner. Staff interviews revealed that the aggressive resident's triggers, such as having his dining room space invaded, were not clearly documented in his care plan until after the incident. Staff also reported frequent aggressive outbursts from this resident, with some staff feeling unable to adequately monitor or manage his behaviors due to staffing limitations. The resident who was the victim of the abuse had mild cognitive impairment and required supervision or assistance for most activities of daily living. Documentation indicated that he did not have a history of aggressive behaviors. During the incident, he was subjected to verbal threats and physical intimidation, leading to fear and a change in his dining habits. The facility's failure to identify and address known triggers for the aggressive resident, as well as insufficient monitoring and intervention, directly contributed to the occurrence of resident-to-resident abuse.
Failure to Ensure Safe Use of Mechanical Lifts During Resident Transfers
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards by not providing adequate supervision and safe equipment use during resident transfers. Specifically, a resident with hemiplegia, severe cognitive impairment, and dependence on staff for transfers was involved in an incident where a manual Hoyer lift tipped over during a transfer from wheelchair to bed. The staff did not fully extend the lift's legs, causing the lift to become unstable and tip, resulting in the resident falling to the floor. Although the resident did not sustain injuries, the incident was attributed to improper use of the lift equipment. Observations revealed that the facility's electric Hoyer lifts were stored in a back hallway among other appliances and were not easily accessible. Staff interviews indicated that the electric lifts had been non-operational for an extended period due to battery issues, leaving only a manual Hoyer lift available for use. Multiple staff members reported that the manual lift felt flimsy and had a tendency to tip, even when used according to instructions. Some staff stated they had reported these concerns to management, but were told the issues were due to user error. Additionally, not all staff received training or competency assessments on the use of the manual Hoyer lift, and some staff reported never receiving education on its use. Documentation showed that the resident required a Hoyer lift for all transfers, and the care plan reflected this need. The facility's investigation identified improper use of the lift as the root cause of the incident. However, the investigation and subsequent staff training were incomplete, as not all nursing staff were included in the competency assessments or in-service education. Furthermore, communication regarding the operational status of the electric Hoyer lifts was inconsistent, with some staff unaware that the electric lifts were available for use again.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
The deficiency involves a failure to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. The report indicates that care was not delivered in alignment with the established plan, which may include not following prescribed treatments or disregarding the expressed wishes and objectives of the resident regarding their care. This lapse resulted in the resident not receiving care as intended by their care plan and medical orders, without mention of any corrective actions or follow-up steps taken after the incident.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. Surveyors observed that the environment contained hazards that could lead to resident accidents, and there was insufficient oversight to mitigate these risks. Specific details regarding the nature of the hazards, the supervision provided, or the residents affected were not included in the report.
Failure to Protect Residents from Abuse and Neglect
Penalty
Summary
A deficiency was identified regarding the facility's failure to protect each resident from all types of abuse, including physical, mental, sexual abuse, physical punishment, and neglect by any individual. The report notes that residents were not adequately safeguarded from these forms of mistreatment, indicating lapses in the facility's responsibility to ensure resident safety and well-being. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Provide and Document Individualized Activity Programs
Penalty
Summary
The facility failed to provide activities designed to support the physical, mental, and psychosocial well-being of three residents, as required by its own policy and federal regulations. For one resident with severe cognitive impairment and a documented interest in dogs and pet therapy, staff did not offer or provide pet therapy during a scheduled session, despite the resident being present in her room and her care plan indicating a strong preference for such activities. Additionally, the television in her room, which could have supported her interests, was not functional and staff were unaware of the location of the remote. Documentation showed that this resident did not attend any emotional activities and only participated in a limited number of intellectual activities over a one-month period, with no evidence of other activity offers or refusals recorded. Another resident, also with severe cognitive impairment and a care plan indicating enjoyment of group activities, pet therapy, and independent leisure materials, was observed not being re-invited to participate in a group ball activity after being distracted and returning to her room. There was no documentation of her participation in social activities or offers of other activities during the review period, despite her care plan specifying regular engagement and individualized interventions. A third resident, who was cognitively intact and expressed a desire to participate in more activities, reported difficulty seeing bingo cards and was not offered pet therapy or other group activities during observed sessions. Documentation for this resident showed no evidence of participation in or offers of emotional, social, physical, or special event activities, and no refusals were recorded. Staff interviews confirmed that activity offers and refusals were inconsistently documented, and that residents were not always invited or encouraged to participate in activities aligned with their preferences and care plans.
Failure to Prevent Unnecessary Use of Psychotropic Medications and Inadequate Documentation
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraints and that the least restrictive approaches were used to address their needs. Specifically, the facility did not include resident-specific non-pharmacological interventions in the behavior care plans for two residents, nor did it document consistent behaviors to justify the continued use of psychotropic medications. Additionally, the care plans lacked documentation of medication-specific target behaviors and person-centered interventions for the psychotropic medications administered to these residents. For another resident, the facility did not ensure that gradual dose reductions (GDR) were attempted for psychotropic medications as required. For one resident with severe cognitive impairment and diagnoses including Alzheimer’s disease, anxiety, and depression, the care plans addressed potential for physical aggression and wandering but did not specify person-centered non-pharmacological interventions. Physician orders included multiple psychotropic medications, but behavior monitoring orders failed to address all identified behaviors, such as physical aggression and wandering. Documentation in the medical record and medication administration records was inconsistent or absent regarding observed behaviors, interventions attempted, and their effectiveness. Staff interviews revealed a lack of knowledge about non-pharmacological interventions and inconsistent documentation practices. Another resident with severe cognitive impairment and multiple diagnoses, including Alzheimer’s disease and insomnia, was prescribed antipsychotic and antidepressant medications. The care plans did not include person-centered non-pharmacological interventions, and there was no physician order to monitor behaviors related to antipsychotic use. Documentation of behaviors and interventions was lacking in the medical record, and staff were unable to consistently describe or document effective interventions. For a third resident with multiple psychiatric diagnoses, the facility did not consistently attempt or document GDRs for psychotropic medications, and when GDRs were contraindicated, the physician did not always provide a rationale. The resident expressed concerns about being on too many medications, and documentation of behaviors and medication reviews was incomplete.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to residents who were unable to perform activities of daily living (ADLs) independently. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs for those individuals. This failure to provide assistance directly affected residents who were dependent on staff for their daily personal care and routine activities.
Failure to Provide and Prevent Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate care for pressure ulcers and did not implement effective measures to prevent the development of new ulcers. This deficiency was identified through observations and record reviews that indicated lapses in the assessment, monitoring, and treatment of pressure ulcers for residents at risk. The report notes that the facility did not consistently follow established protocols for pressure ulcer care, resulting in inadequate prevention and management.
Failure to Provide Appropriate Care for Range of Motion and Mobility
Penalty
Summary
A deficiency was identified regarding the provision of care to maintain or improve a resident's range of motion (ROM), limited ROM, and/or mobility. The facility failed to provide appropriate care or services to prevent a decline in these areas, except in cases where a decline was medically unavoidable. The report notes that the necessary interventions to support or enhance the resident's ROM or mobility were not implemented as required.
Deficient Bowel/Bladder and Catheter Care Practices
Penalty
Summary
The report identifies a deficiency related to the provision of care for residents who are continent or incontinent of bowel and bladder. It also notes failures in providing appropriate catheter care and in implementing measures to prevent urinary tract infections. The deficiency is based on observations or findings that the facility did not consistently ensure proper care practices for these residents, as required by regulatory standards.
Improper Use and Care of Feeding Tubes
Penalty
Summary
Feeding tubes were used for a resident without clear documentation of a medical reason or evidence that the resident agreed to the intervention. Additionally, appropriate care and services related to the feeding tube were not provided as required. These actions resulted in a deficiency related to the use and management of feeding tubes for residents.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A resident who displays or is diagnosed with dementia did not receive the appropriate treatment and services. The facility failed to ensure that the necessary care was provided to address the resident's dementia-related needs, as required by regulatory standards. This deficiency was identified during the survey process.
Unnecessary Drugs in Resident Drug Regimens
Penalty
Summary
A deficiency was identified regarding the management of residents' drug regimens. The facility failed to ensure that each resident’s drug regimen was free from unnecessary drugs, as required by regulations. This indicates that at least one resident was prescribed or administered medications that were not clinically indicated, excessive in dose or duration, or duplicative, without adequate justification documented in the medical record.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not following proper procedures for a resident on enhanced barrier precautions (EBP). Specifically, a certified nurse aide (CNA) was observed emptying a resident's catheter bag without donning gloves or a gown, contrary to both CDC guidance and the facility's own catheter care policy. The resident in question had a catheter and was on EBP, which requires the use of personal protective equipment (PPE) such as gloves and gowns during high-contact care activities. Interviews with staff revealed gaps in training and adherence to infection control protocols. One CNA reported not having received catheter care training at the facility, though she was aware that gloves and a gown should be worn when emptying catheter bags. Both the infection preventionist (IP) and the director of nursing (DON) confirmed that EBP should be followed for residents with catheters, including the use of appropriate PPE during catheter care. The failure to use PPE as required was acknowledged as improper by facility leadership.
Failure to Honor Residents' Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor the residents' right to choose their attending physician, affecting four out of six sampled residents. The deficiency arose when the facility changed medical provider groups without adequately assisting residents in making an informed choice about their attending physician. The facility's policy, which guarantees residents the right to be informed and choose their attending physician, was not followed. Interviews with residents revealed that they were either not offered a choice or not informed about their right to select a physician, nor were they informed about which physicians were covered by their insurance. The facility's electronic medical records contained unsigned and undated provider choice documents, indicating that the residents' consent was not properly obtained. Staff interviews revealed that the previous facility owner had restricted physician choices to a newly contracted medical group, and the new ownership continued this practice by offering only two new physicians for residents to choose from. The Social Services Director admitted to assisting residents in choosing a physician without providing complete information about insurance coverage, and the provider choice forms were completed without the residents' or their legal representatives' signatures.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 102 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Colorado Springs
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pikes Peak Post Acute | 0.6 mi | ★★★★★ | 2 | 0 |
| Springs Village Care Center | 1.7 mi | ★★★★★ | 1 | 0 |
| Sunny Vista Living Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Medallion Post Acute Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| The Healthcare Resort Of Colorado Springs | 2.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.