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 Life Care Center Of Colorado Springs during CMS and state inspections, most recent first.
A high fall‑risk resident with traumatic brain injury, seizures, dementia, impaired mobility, and impaired vision experienced multiple falls, including one with head and facial lacerations requiring hospital treatment, while care‑planned fall‑prevention measures and supervision were not consistently implemented. The care plan called for the bed to be kept in the lowest position, floor mats at the bedside, the call light and personal urinal within reach, and close supervision, but surveyors observed the bed not in the lowest position, no floor mats in place, and the urinal out of reach. The resident was also observed beginning to fall forward from a wheelchair while an RN at the nearby nurses’ station was not watching him until prompted, and he was left unattended in the shower room despite being identified as a high fall risk. Documentation of several falls lacked clear root cause analysis or review of the effectiveness of existing interventions, demonstrating a pattern of inconsistent implementation of person‑centered fall‑prevention strategies and supervision.
Staff failed to follow Enhanced Barrier Precautions (EBP) and hand hygiene requirements during care of multiple residents. In several instances, CNAs and an LPN provided wound care, incontinence care, and linen changes to residents on EBP using only gloves and no gowns, despite posted EBP signage and available PPE. During one wound dressing change, an LPN did not change gloves between removing a soiled dressing and preparing a new one. In another case, an RN administered tube feeding to a resident with a feeding tube while wearing gloves and a mask but no gown, and initially believed the resident was not on EBP. These events occurred despite facility policy and CDC-based expectations for gown and glove use during high-contact care activities and proper hand hygiene.
Surveyors identified a deficiency when expired OTC medications, including CoQ10, calcium, and acetaminophen, were found on a medication cart, despite facility policy requiring house stock medications to be stored in original containers with visible expiration dates and discarded when expired. An RN reported being trained to date OTC bottles when opened and discard them three months later, while an LPN demonstrated uncertainty about whether to follow a post-opening timeframe or the manufacturer’s expiration date and did not know where to find the facility’s policy. The DON stated staff were expected to follow manufacturer expiration dates, acknowledged that nurses were informally trained by other bedside staff, and confirmed there was no specific facility training on medication expiration dates, while also stating that expired medications should not be administered because they could make a resident very sick.
A resident on hospice with hypertensive heart disease, heart failure, palliative care, and protein-calorie malnutrition did not have a current hospice plan of care or hospice visit documentation readily accessible in the EMR or physical chart. The hospice care plan on file was outdated, and there were no hospice visit notes for days when an RN and an LPN reported that hospice staff had seen the resident. Staff described an informal process where hospice CNAs and RNs checked in verbally, with no formal sign-in system or structured method for documenting or tracking hospice visits and services, and the DON acknowledged poor communication from the hospice provider while recognizing the facility’s responsibility for ensuring appropriate hospice services.
A resident with moderate cognitive impairment and a history of wandering was not properly supervised during an off-site medical appointment, leading to the individual leaving the clinic unsupervised and being missing for several hours. Despite documented wandering behaviors and cognitive deficits, staff did not reassess elopement risk or implement a care plan, and miscommunication among staff resulted in no escort being provided.
The facility failed to provide a resident with speech difficulties due to a stroke with an appropriate communication tool, leading to ineffective communication of her needs. Staff were unaware or did not use the communication board, and the care plan lacked specific instructions.
The facility failed to assist a resident with applying her compression stockings, necessary for treating her bilateral lower leg edema. Despite the resident's cognitive intactness and ability to dress herself, she required assistance with the stockings, which staff did not consistently provide. Observations and interviews revealed the resident's feet were often swollen, and she was seen without the stockings, indicating non-compliance with physician's orders and facility policy.
Failure to Consistently Implement Fall-Prevention Interventions and Supervision for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a high fall‑risk resident received adequate, person‑centered supervision and that fall‑prevention interventions identified in the care plan were consistently implemented. The resident was an older adult with traumatic subdural hemorrhage, seizures, dementia, generalized weakness, impaired mobility, impaired vision, cognitive communication deficit, and a history of multiple falls. The 1/14/26 MDS showed the resident was cognitively intact by BIMS but had fluctuating difficulty focusing attention and had already experienced multiple falls, including one with injury, since admission. The fall care plan, revised on 12/10/25 and 1/23/26, identified the resident as at risk for falls due to impaired mobility, history of falls, impaired vision, seizures, and psychotropic medication use, and called for specific interventions such as keeping the bed in the lowest position at all times, placing floor mats at the bedside, ensuring the call light and personal urinal were within reach, and moving the resident to a room across from the nurses’ station. Surveyor observations showed that these care‑planned interventions were not consistently in place. On 2/24/26, the resident was observed in his wheelchair in his room, leaning forward toward the floor and beginning to fall forward with his legs buckling, while an RN sat at the nurses’ station across the hall but was not watching him until prompted. The RN then had to physically assist the resident back to a safe sitting position and instructed him to use his call light. On 2/26/26, the resident was observed sleeping in bed with the bed not in the lowest position, no floor mats at the bedside, and his personal urinal not within reach, despite the care plan requiring all three interventions to prevent falls. These observations demonstrated that the facility did not consistently provide the level of supervision and environmental controls it had identified as necessary for this resident. The record review documented a pattern of repeated falls, many unwitnessed, with incomplete or inconsistent post‑fall analysis and follow‑through. The resident sustained multiple falls in the bathroom, from bed, from a low bed, during attempts to walk with a friend, and while attempting to transfer or reach for objects without assistance. On 11/22/25, he was found on the bathroom floor with root cause attributed to gait imbalance and an intervention to offer frequent toileting. On 11/24/25 and 11/26/25, he fell while attempting to walk with a friend and while trying to retrieve his cell phone, but the progress notes did not document a root cause analysis or review of the effectiveness of existing interventions or need for new ones. On 12/1/25 and 12/6/25, he was found on the floor after rolling or falling from bed, with one fall linked to toileting urgency and possible UTI, but again without consistent documentation of reassessment of interventions. Further falls continued despite the resident’s high‑risk status and care‑planned interventions. On 12/9/25, he had two falls: one witnessed as he attempted to get out of bed unassisted, and a later unwitnessed fall in which he was found on the floor bleeding from lacerations to his forehead and jaw after attempting to empty a urinal without using his call light, resulting in transfer to the hospital for treatment. On 12/10/25, he reported sliding from bed and getting himself back in, and on 12/16/25 he fell in the shower room after sliding from the shower chair while reaching to turn off the water; the CNA had left him unattended in the shower room for a few minutes, even though the DON later stated that a resident with a high fall‑risk diagnosis should not be left alone there. On 12/31/25, he fell while trying to get into bed when he could not find his call light, which had fallen and become wrapped around the wheelchair wheel, and on 1/19/26 he fell in the bathroom while transferring from the toilet to his wheelchair without assistance when the wheelchair was not locked. Staff interviews confirmed that the resident was very impulsive, had been falling frequently, and required close supervision, yet the documented lapses in supervision, inconsistent implementation of care‑planned interventions, and incomplete root cause analyses after several falls led surveyors to conclude that the facility failed to provide adequate supervision and consistently implement person‑centered fall‑prevention measures for this resident.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and hand hygiene. Facility policy, consistent with CDC guidance, required targeted gown and glove use during high-contact resident care activities for residents with MDROs, wounds, or indwelling medical devices, and required staff to follow IPCP standards including hand hygiene and appropriate PPE use. Despite posted EBP signage and availability of PPE, staff did not consistently don required gowns or perform appropriate hand hygiene during resident care. For one resident with MDRO in the urine and an EBP sign posted outside the room, two CNAs entered to provide incontinence and perineal care without donning gowns, using only gloves as PPE. One CNA later confirmed she provided incontinence and perineal care using only gloves. These actions occurred despite the presence of an EBP sign and a bin of isolation gowns outside the room, and despite facility policy requiring gown and glove use for high-contact care activities under EBP. For another resident on EBP with a posted sign specifying that gloves and a gown must be worn for activities such as wound care, incontinence care, and linen changes, an LPN and a CNA performed coccyx wound care, incontinence care, and a linen change without wearing gowns. The LPN removed a soiled wound dressing and prepared a new dressing without changing gloves between tasks, contrary to hand hygiene expectations. Both staff acknowledged the importance of hand hygiene and PPE but reported not having received education or training on EBP requirements. In a third case, an RN provided tube feeding to a resident with a feeding tube while wearing gloves and a mask but no gown, and initially stated the resident was not on EBP. The IP later stated she had only just become aware of the resident’s feeding tube and had not yet entered EBP orders, despite the process requiring EBP determination at admission for residents with indwelling devices. These observations across three units demonstrate failures to ensure appropriate PPE use for residents on or meeting criteria for EBP and failures in hand hygiene practices during wound care, in direct conflict with CDC guidance and the facility’s own IPCP policy.
Expired OTC Medications Found on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that over-the-counter (OTC) medications were stored and discarded in accordance with manufacturer expiration dates and facility policy. The facility’s House Stock Items policy required house stock medications to be stored in the original manufacturer’s container with the medication name, strength, expiration date, and lot number clearly visible. During an observation of a medication cart on the 300 east hall with an LPN, surveyors found multiple OTC medications with manufacturer expiration dates that had already passed, including CoQ10 100 mg, Calcium 500 mg, and Acetaminophen 500 mg. These medications remained on the cart despite being expired according to the dates printed on the manufacturer’s containers. Staff interviews revealed inconsistent understanding and training regarding OTC medication expiration and storage. An RN reported she had been trained to write the open date on OTC medications and to discard them three months after that date. The LPN observed with the cart stated she was unsure whether OTC medications expired 30 days after opening or followed the manufacturer’s expiration date, did not know where to find the facility’s OTC storage and expiration policy, and was unsure why staff were writing open dates on OTC bottles, though she acknowledged that medications should be discarded if the manufacturer’s expiration date had passed. The DON stated that nursing staff were expected to reference the manufacturer’s expiration date on OTC medications, acknowledged that nurses were trained informally by other bedside staff, and confirmed the facility did not provide specific training on medication expiration dates for either pharmacy-dispensed or OTC medications. The DON stated that expired medications should not be administered because they could make a resident very sick.
Failure to Maintain Current Hospice Care Plans and Documentation
Penalty
Summary
The facility failed to meet hospice care requirements for a resident receiving hospice services by not maintaining readily accessible, current hospice documentation and by not clearly delineating care responsibilities between the facility and the hospice provider. The hospice agreement required both parties to keep complete, detailed, and readily accessible clinical records, organized to facilitate retrieval. For a resident over age 65 with hypertensive heart disease with heart failure, palliative care, and protein-calorie malnutrition, the electronic medical record contained a hospice plan of care that was only current through a certification period ending in mid-November 2025, with no updated hospice plan of care for the subsequent certification period beginning in January 2026. The resident’s hospice care plan in the facility record, initiated in March 2024 and revised in July 2024, included an intervention to work cooperatively with the hospice team, but there was no current hospice care plan from the hospice team in the record. Surveyors’ review of the resident’s electronic and physical charts did not show clinical documentation from routine hospice visits, including no visit notes from hospice staff on specific days when facility nurses reported hospice staff had been present. An RN stated that neither the physical chart nor the EMR contained the most recent hospice care plan and acknowledged that hospice notes were not updated or in chronological order. The RN also reported there was no system for hospice staff to sign in or for the facility to ensure required weekly hospice visits were completed, and that hospice CNAs typically came on certain days to assist with bathing without a formal system for charting or reporting the care provided. An LPN confirmed seeing hospice staff on particular days and relied on their informal check-ins rather than reviewing the chart, which lacked corresponding visit notes. The DON acknowledged that communication from the hospice company was poor and affirmed that the facility was ultimately responsible for ensuring hospice services were provided appropriately, yet the records did not demonstrate that hospice services and care planning requirements were being met for this resident.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, aphasia, encephalopathy, and a history of wandering was not provided with adequate supervision during an off-site medical appointment. The resident was scheduled for transportation to a neurology clinic and required an escort due to his cognitive and behavioral status. Despite multiple progress notes documenting the resident's wandering and confusion, the facility failed to identify him as an elopement risk prior to the incident, and no care plan addressing elopement was in place at the time of the event. On the day of the incident, the resident was transported to his appointment by an outside medical transportation company and escorted into the clinic. After the appointment concluded, the resident was discharged from the clinic and left the premises unsupervised. The transportation driver, scheduled to return later, was unable to locate the resident and notified the facility. Facility staff initiated a search, and the resident was eventually found several hours later, walking miles away from the clinic. Interviews and documentation revealed that there was confusion and miscommunication among facility staff regarding who was responsible for escorting the resident, with some staff believing the resident's representative would attend, while others were aware that the representative could not be present and had requested a staff escort. The facility's elopement risk assessments did not accurately reflect the resident's cognitive impairments and history of wandering, as documented in progress notes and diagnoses. Staff interviews confirmed that the resident had exhibited wandering behaviors and required frequent redirection, yet these observations did not prompt a reassessment of elopement risk or the implementation of appropriate interventions. The lack of a clear process for ensuring supervision during off-site appointments and the failure to update the resident's care plan contributed directly to the resident's unsupervised elopement.
Failure to Provide Appropriate Communication Tool for Resident
Penalty
Summary
The facility failed to provide a resident who had difficulties with speech due to a stroke with an appropriate communication tool to ensure effective communication of her needs. The resident, who was cognitively intact and required assistance for daily activities, was observed struggling to communicate with staff using gestures. Staff members were unable to understand her needs, and there was no clear communication tool available in her room. The care plan indicated the use of alternative communication tools but did not specify what those tools were, leading to confusion among staff members. Interviews with staff revealed that some were unaware of the existence of a communication board, while others knew about it but did not use it. The communication board was not readily accessible, and there was no clear indication of its location. The speech therapist had not assessed the resident for the use of a communication board, and the social services assistant was also unaware of its existence. Despite the unit care coordinator's intention to update the care plan, it was not done before the end of the survey.
Failure to Assist Resident with Compression Stockings
Penalty
Summary
The facility failed to ensure Resident #55 received treatment and care in accordance with professional standards of practice. Specifically, the facility did not assist the resident with applying her compression stockings, which were necessary to treat her bilateral lower leg edema. Despite the resident's cognitive intactness and her ability to dress herself, she required assistance with the compression stockings, which staff failed to provide consistently. Observations and interviews revealed that the resident's feet were swollen, and she was often seen without the compression stockings, indicating a lack of adherence to the physician's orders and the facility's policy on anti-embolism stocking application. The resident reported that staff did not help her put on her compression stockings, which she could not manage on her own due to the difficulty of pulling them up. On multiple occasions, the resident was observed with swollen feet and without the compression stockings. Staff members, including a CNA and an LPN, were either unaware of the resident's need for assistance or felt uncomfortable applying the stockings due to the swelling. The unit care coordinator incorrectly believed the resident was supposed to apply the stockings herself, despite the resident's repeated requests for help. A review of the resident's medical records showed a physician's order for compression stockings, but this order was not correctly entered into the system, leading to a lack of documentation and follow-through by the staff. The DON acknowledged the error and the absence of documentation indicating the resident's refusal to wear the stockings. The care plan was not updated to reflect the physician's order, contributing to the oversight in providing the necessary care for the resident's edema.
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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) |
|---|---|---|---|---|
| Advanced Health Care Of Colorado Springs | 0.1 mi | ★★★★★ | 0 | 0 |
| Fountain View Rehabilitation And Nursing Llc | 0.8 mi | ★★★★★ | 2 | 0 |
| Sunny Vista Living Center | 1.1 mi | ★★★★★ | 0 | 0 |
| Medallion Post Acute Rehabilitation | 1.2 mi | ★★★★★ | 0 | 0 |
| Falcon Heights Rehabilitation And Nursing Llc | 1.6 mi | ★★★★★ | 2 | 0 |
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