Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Fountain View Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
The facility failed to prevent resident-to-resident physical abuse when two cognitively impaired residents with known behavioral issues were seated together in the dining room. One resident, who frequently reached for others’ desserts, took the dessert of another resident who was known by staff to be territorial over belongings and food and to become aggressive in such situations. In response, the territorial resident slammed his hands on the table, hit the other resident in the chest, and verbally insulted him. Staff interviews confirmed prior knowledge of both residents’ behaviors, and records showed that the dessert-seeking behavior was not included in the care plan, despite the residents’ dementia, behavioral histories, and need for close supervision.
The facility did not ensure timely responses to call lights, resulting in residents waiting extended periods—sometimes up to several hours—for assistance, particularly at night and on weekends. Multiple residents reported distress and discomfort due to these delays, including being left in soiled briefs and after falls. Staff and visitor interviews, as well as grievance records, confirmed that long call light wait times were a persistent issue, and audits failed to capture the most problematic shifts.
The facility failed to employ a Certified Dietary Manager or ensure full-time oversight by a Registered Dietitian for dietary services. The Dietary Manager was not certified and lacked a current ServSafe certification, having completed only part of a CDM course. The RD was present only twice a week, which did not provide full-time oversight. This increased the potential risk of residents not receiving diets specific to their needs and inadequate kitchen sanitation.
The facility's kitchen was found in an unsanitary condition, with food debris and dust on carts, prep tables, and equipment. The Dietary Manager failed to maintain temperature and sanitizer logs for the dish machine, with wash temperatures below the required level and sanitizer levels unmeasured. The Administrator confirmed the absence of logs since new forms were initiated, and the DM admitted to not prioritizing kitchen cleaning.
The facility failed to create comprehensive care plans with measurable goals for several residents, including those with multiple sclerosis, sleep apnea, and end-stage renal disease. Additionally, care plans for vision, hearing, and dental status were missing for two residents. The care plans often contained vague goals without specific, measurable outcomes, contrary to the facility's policy. A registered nurse confirmed that care plan goals were expected to be measurable.
The facility failed to ensure narcotic counts were consistently completed at each shift change on four medication carts, as required by policy. Missing signatures on the Controlled Drugs Count Record/Date indicated that the required counts were not properly documented. Interviews with RNs and LPNs confirmed they forgot to sign the records, acknowledging the oversight.
The facility failed to serve the correct portion sizes during a lunch service, affecting 13 trays. The Dietary Manager observed that carrots were served with a 4-ounce scoop instead of the planned 3-ounce, and mechanical chopped meat was served with a 3-ounce scoop instead of the required 4-ounce. The DM corrected the scoop sizes after noticing the error.
The facility failed to provide written notice of transfer/discharge for two residents who were hospitalized. Despite notifying emergency contacts by phone, the facility did not provide the required written documentation explaining the reason for discharge, the effective date, and appeal information. One resident had severe cognitive impairment and was discharged due to a mental status change, while the other was cognitively intact and discharged for osteomyelitis and possible toe amputation.
The facility failed to provide written notice of the bed hold policy to two residents or their representatives during hospital transfers, as required by their policy. In both cases, there was no evidence of written notification being provided, despite verbal agreements being made. This deficiency was identified for two residents out of a sample of 23.
A resident in isolation due to COVID-19 was not provided with adequate activities beyond watching TV, despite having a care plan that included preferences for music, reading, and one-on-one visits. Observations and interviews revealed that staff did not consistently engage the resident in activities, and the Activity Staff could not recall providing the activity cart. The DON confirmed that one-on-one visits should have continued.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and intervention to prevent physical abuse between residents, resulting in one cognitively impaired resident physically striking another during a meal. The facility’s abuse, neglect, and exploitation policy requires deployment of trained and qualified staff in sufficient numbers who know residents’ care needs and behavioral symptoms, and mandates prevention of all types of abuse. Despite this, staff interviews and the facility’s own investigation showed that staff were aware of one resident’s frequent behavior of reaching for and taking other residents’ desserts, and another resident’s territorial behavior and history of becoming aggressive when his belongings or food were disturbed. On the date of the incident, both residents, each with severe cognitive impairment and behavioral histories, were seated together at the same dining table. During the meal, the cognitively impaired resident with a history of grabbing desserts reached out and took the other resident’s dessert. In response, the territorial resident slammed his hands on the table, hit the dessert-taking resident in the chest, and called him names. A CNA witnessed the event and confirmed that the altercation occurred immediately after the dessert was taken. The facility’s investigation documented that both residents had severe cognitive impairment with behaviors and concluded that physical abuse had occurred. Record review showed that the victim resident had diagnoses including cognitive, social, or emotional deficit following cerebral infarction, mood disorder due to a physiological condition, generalized muscle weakness, and lower leg contractures, and was totally cognitively impaired with a BIMS score of 0, requiring maximum assistance with all ADLs. His care plan addressed impaired cognitive function and communication strategies but did not document his behavior of reaching for other residents’ desserts. The assailant resident had dementia with psychotic, mood, and anxiety components, cognitive impairment with a BIMS score of 5, and a care plan noting confusion, delusional thought processes, and a suspected trauma history contributing to possessiveness of space and reactive responses. Staff interviews confirmed that this resident was territorial over belongings, became aggressive if someone took his food, and had a history of verbal threats and attempts to hit or grab when close to others. The NHA acknowledged that the victim’s dessert-seeking behavior was not care planned and that the two residents, given their known behaviors, should not have been seated together, leading to the abusive incident.
Failure to Ensure Timely Call Light Response and Resident Dignity
Penalty
Summary
The facility failed to maintain residents' dignity and respect by not ensuring timely responses to call lights, as required by their own policy. Multiple residents reported excessive wait times for assistance after activating their call lights, with some waiting up to two or three hours, particularly during night shifts and weekends. These delays were corroborated by resident interviews, a frequent visitor, and grievance records, all indicating that long response times were a persistent issue. Residents expressed feelings of frustration, anxiety, and distress due to these delays, especially when assistance was needed for toileting, mobility, or after falls. One resident described being left in soiled briefs for extended periods, resulting in skin irritation and emotional distress. Another resident recounted waiting up to two hours for help, and a third reported a fall where assistance did not arrive for thirty minutes. Grievance forms and interviews revealed that residents had repeatedly raised concerns about call light response times, both individually and through the resident council, but the issue persisted. Staff interviews confirmed that call light response times were often prolonged, especially when staffing levels were inadequate due to call-outs or insufficient coverage during certain shifts. Facility records showed that call light audits were conducted, but these were limited to daytime hours and did not address the periods when residents reported the longest delays. The audits and grievance documentation further substantiated that call lights were not consistently answered within the facility's policy timeframe. Despite staff education and some interventions, the deficiency remained evident through ongoing resident complaints, documented grievances, and audit findings.
Deficiency in Dietary Management and Oversight
Penalty
Summary
The facility failed to employ a Certified Dietary Manager (CDM) or ensure full-time oversight by a Registered Dietitian (RD) for the dietary services provided to all 83 residents. The Dietary Manager (DM) had only recently started working in the role and was not certified, having completed only 40 hours of a 120-hour CDM course. Additionally, the DM lacked a current ServSafe certification. The RD was only present at the facility twice a week, which did not provide full-time oversight for the dietary services. The job descriptions for the DM position required certification as a dietary manager or food service manager and an active food handler's permit/ServSafe certification. However, the DM was initially hired as a cook and later transitioned to the DM role without meeting these qualifications. The Administrator confirmed the DM's lack of certification and the part-time presence of the RD. This situation increased the potential risk that residents might not receive diets specific to their needs and that basic kitchen sanitation might not be maintained.
Sanitation and Log Maintenance Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain the kitchen in a sanitary condition and did not keep temperature and sanitizer logs for the dish machine, which increased the risk of food contamination for all 83 residents. During an initial kitchen tour, surveyors observed that two plastic carts holding clean dishes and condiments were covered in food debris, dust, and water splatter marks. The bottom shelves of prep tables and a meat slicer were also found with dust and dried food debris. Additionally, the reach-in refrigerator and freezer had spills and streaks of food debris, and the kitchen floor was dirty with food debris. The Dietary Manager (DM) demonstrated the use of the dish machine, revealing that the wash temperature was below the required 120 degrees, and the sanitizer level had not been measured that day. The DM admitted that temperature and sanitizer logs were not maintained, and the logs were supposed to be recorded at least three times a day. The DM also acknowledged that the kitchen had not been cleaned properly, despite being aware of the sanitation issues. The Administrator confirmed that logs had not been maintained since new forms were initiated, and the DM verified that the logs were only started with the dinner meal on the day of the survey.
Facility Fails to Develop Measurable Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans with measurable goals for seven out of 23 sampled residents. These residents had various medical conditions, including multiple sclerosis, anxiety, sleep apnea, hemiplegia, hemiparesis, transient cerebral ischemic attack, bipolar disease, chronic respiratory failure, and end-stage renal disease. The care plans lacked specific, measurable objectives and timetables to address these conditions effectively. For instance, the care plan for a resident with hypothyroidism only stated a goal of being free of signs and symptoms through the review date, without specifying measurable outcomes. Additionally, the facility did not develop care plans to address vision, hearing, and dental status for two residents. One resident with a history of traumatic brain injury and hemiplegia did not have a care plan for dental status, while another resident with end-stage renal disease and a below-knee amputation lacked a care plan for hearing and vision deficits. This oversight could potentially lead to unmet care needs for these residents, as their specific conditions were not adequately addressed in their care plans. The facility's policy on care plans, adopted in December 2016, requires comprehensive, person-centered care plans with measurable objectives and timeframes. However, the care plans reviewed did not meet these criteria, as they often contained vague goals such as minimizing risks and injury potential or being free of discomfort without clear, measurable outcomes. During an interview, a registered nurse confirmed that the expectation was for care plan goals to be measurable, indicating a discrepancy between policy and practice.
Failure to Document Narcotic Counts at Shift Changes
Penalty
Summary
The facility failed to ensure that a narcotic count was consistently completed at each shift change on four of four medication carts, as required by their policy on controlled substances. The policy mandates that nursing staff must count controlled medications at the end of each shift, with both the oncoming and off-going nurses making the count together and signing the Controlled Drugs Count Record/Date. However, the review of these records revealed multiple instances where signatures were missing, indicating that the required narcotic counts were not properly documented. Specifically, the Weeping unit, Spring Canyon unit, Columbine unit, and Evergreen unit medication carts all had missing nurse signatures on various dates. Interviews with the nursing staff, including RNs and LPNs, confirmed that they had forgotten to sign the records, acknowledging the oversight. This lack of documentation suggests that the narcotic counts may not have been conducted as required, potentially leading to unaccounted narcotic medications.
Incorrect Portion Sizes Served During Lunch
Penalty
Summary
The facility failed to serve the preplanned portion sizes during a lunch service, affecting 13 out of 13 trays observed from a total of 83 trays. This issue was identified during an observation of the lunch tray line, where the portion of carrots on the first 12 trays appeared excessively large, occupying half of the plate. The Dietary Manager (DM) confirmed that the carrots were supposed to be a 3-ounce serving, but the cook was using a 4-ounce scoop. The DM corrected this by replacing the scoop with the correct size. Additionally, the mechanical chopped meat was served with a 3-ounce scoop instead of the required 4-ounce scoop, which was corrected after being observed on one tray. The DM acknowledged that the scoops were placed by the cook before the food service began, and he did not notice the incorrect scoop sizes for the carrots and meat. The Week at a Glance-Week 2 menu confirmed that both the meat and vegetable portion sizes should have been four ounces.
Failure to Provide Written Notice of Transfer/Discharge
Penalty
Summary
The facility failed to provide a written notice of transfer or discharge for two residents, R21 and R17, who were hospitalized. According to the facility's policy, a Notice of Discharge/Transfer should be given to the resident or their representative, explaining the reason for discharge, the effective date, and information on how to appeal. However, in both cases, the facility only notified the residents' emergency contacts via telephone and did not provide the required written documentation. Resident R21, who had severe cognitive impairment as indicated by a BIMS score of 99, was discharged to the hospital due to a mental status change, poor intake, and vomiting. Similarly, Resident R17, who was cognitively intact with a BIMS score of 13, was discharged for osteomyelitis and a possible toe amputation. In both instances, there was no documentation in the electronic medical records that written transfer/discharge information was provided to the residents' emergency contacts, which is a violation of the facility's discharge policy.
Failure to Provide Written Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide written notice of the bed hold policy to residents or their representatives during hospital transfers, as required by their policy. This deficiency was identified for two residents, R21 and R17, out of a sample of 23. The facility's policy, adopted in December 2017, mandates that residents be informed of the bed hold policy upon admission and prior to any transfer for hospitalization. However, in both cases reviewed, there was no evidence of written notification being provided to the residents' emergency contacts. Resident R21, who had severe cognitive impairment, was transferred to the hospital due to a mental status change, poor intake, and vomiting. Despite this, there was no record of written notification of the bed hold policy being sent to the emergency contact. Similarly, Resident R17, who was cognitively intact, was transferred to the hospital for osteomyelitis and a possible toe amputation. Although a verbal agreement was made over the phone regarding the bed hold, no written notification was provided. The bed hold rate was marked as N/A on the form, and the call was documented by RN1, who confirmed that the notification was given verbally rather than in writing.
Failure to Provide Adequate Activities for Isolated Resident
Penalty
Summary
The facility failed to provide adequate activities for a resident (R59) who was under transmission-based precautions due to a positive COVID-19 status. The resident, who had moderate cognitive impairment, was observed to have limited engagement in activities other than watching television while in isolation. Despite having a care plan that included preferences for listening to music, reading, and one-on-one visits with staff, these activities were not provided consistently. Observations on multiple days revealed that staff did not enter the resident's room to offer activities, except for basic care tasks like serving meals and repositioning. Interviews with the resident and facility staff confirmed the lack of one-on-one activities during the isolation period. The resident expressed a desire for reading materials and one-on-one interactions, which were not provided until after the issue was raised with the facility staff. The Activity Director and Activity Staff acknowledged the oversight, with the Activity Staff unable to recall if they had provided the activity cart to the resident during the week. The Director of Nursing stated that one-on-one visits should have continued for residents in isolation, indicating a lapse in the implementation of the facility's activity program policy.
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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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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) |
|---|---|---|---|---|
| Falcon Heights Rehabilitation And Nursing Llc | 0.8 mi | ★★★★★ | 2 | 0 |
| Life Care Center Of Colorado Springs | 0.8 mi | ★★★★★ | 5 | 1 |
| Advanced Health Care Of Colorado Springs | 1 mi | ★★★★★ | 0 | 0 |
| Medallion Post Acute Rehabilitation | 1.7 mi | ★★★★★ | 0 | 0 |
| Sunny Vista Living Center | 1.9 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.