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 Sunny Vista Living Center during CMS and state inspections, most recent first.
Surveyors found that kitchen equipment, including steam table pans and cutting boards, were not stored or maintained in a clean and sanitary manner, with some items being wet, scored, or burned. Additionally, perishable foods were not always discarded after expiration, as evidenced by expired and spoiled items found in storage. These deficiencies occurred despite staff awareness of proper procedures.
Several residents were administered psychotropic medications, including antipsychotics, without proper documentation of behaviors or evidence that non-pharmacological interventions were attempted first. Care plans often lacked individualized, person-centered interventions, and behavior monitoring was incomplete or not updated. Staff interviews confirmed inconsistent documentation and a lack of awareness of resident-specific interventions, and trauma-informed care was not incorporated for residents with trauma responses.
Drugs and biologicals were not labeled according to professional standards, and medications, including controlled drugs, were not stored in locked or separately locked compartments as required.
A resident did not receive care and treatment in accordance with physician orders and their own stated preferences and goals, as observed and documented by surveyors.
A resident with a mental disorder and a history of trauma did not receive the necessary treatment and services to address their psychosocial needs, resulting in a deficiency related to inadequate individualized care.
Surveyors observed that housekeeping staff did not perform hand hygiene between glove changes or between cleaning different rooms, failed to allow disinfectant to remain on surfaces for the required dwell time, and missed high-touch surfaces during cleaning. Additionally, during catheter care for a resident, an infection preventionist did not perform hand hygiene after glove removal or before donning new gloves, and touched potentially contaminated surfaces without appropriate hand hygiene. These actions were not in accordance with CDC guidelines or facility policy, resulting in a deficiency in the infection prevention and control program.
The facility failed to provide trauma-informed care for two residents with PTSD, as required by their policy. The care plans for these residents did not include person-centered interventions or identification of PTSD triggers. The social service director was unaware of one resident's PTSD diagnosis and expressed discomfort in conducting trauma assessments, contributing to the deficiency.
A resident with major depressive disorder and aphasia experienced increasing depression and expressed a wish to die, yet the facility failed to update the care plan or provide timely psychosocial support. The resident's antidepressant medication was inaccurately documented, and psychological services were only referred after family insistence. Staff interviews confirmed a lack of awareness and documentation regarding the resident's worsening condition.
Deficient Sanitary Food Storage and Handling in Kitchen
Penalty
Summary
Surveyors identified deficiencies in the facility's main kitchen related to the storage, distribution, and serving of food in a sanitary manner. During an initial kitchen tour, multiple stacks of steam table pans were found stored with moisture trapped between them, and several cutting boards were observed to be scored, gouged, or burned, making them difficult to clean and sanitize effectively. Additional observations in the walk-in refrigerator revealed more scored cutting boards and further instances of wet steam table pans being stacked together. These conditions were not in accordance with professional standards, which require that food-contact surfaces be maintained in a clean and sanitary state and that equipment be kept free of residue and debris. Further inspection revealed that perishable foods were not consistently discarded after their expiration dates. Specifically, a pan of egg salad was found with a discard date that had already passed, and pans of blueberries and lettuce were undated and exhibited a white film on their surfaces, indicating spoilage. Staff interviews confirmed that there were established procedures for replacing damaged equipment and discarding expired or spoiled food, but the observed conditions indicated these procedures were not consistently followed.
Failure to Prevent Unnecessary Psychotropic Medication Use and Ensure Least Restrictive Interventions
Penalty
Summary
The facility failed to ensure that five out of nine sampled residents were free from unnecessary psychotropic medications and chemical restraints, and did not consistently use the least restrictive approaches for their needs. Specifically, there was a lack of documentation for prescribed PRN antipsychotic medications, missing records of identified behaviors, and insufficient evidence of non-pharmacological interventions prior to medication administration. For several residents, care plans did not include medication-specific target behaviors or person-centered interventions, and behavior monitoring was either absent or not updated to reflect individualized approaches. For one resident with severe cognitive impairment and multiple psychiatric diagnoses, antipsychotic medications were administered without corresponding documentation of behaviors or non-pharmacological interventions. The medical record did not reflect the behaviors that justified the use of these medications, and care plans failed to include triggers or person-centered interventions. In another case, a resident with dementia and depressive disorder was prescribed antipsychotic medication, but there was no documentation of behaviors or mood charting as ordered, and recommendations from psychological assessments were not incorporated into care plans or behavior monitoring. Other residents with intellectual disabilities, schizoaffective disorder, and depression were also affected by similar deficiencies. Their care plans lacked individualized interventions, and behavior monitoring did not consistently document specific behaviors or the use and effectiveness of non-pharmacological interventions. Staff interviews revealed a lack of awareness regarding resident-specific interventions and inconsistent documentation practices. Additionally, trauma-informed care was not integrated into care plans or behavior monitoring for residents with identified trauma responses.
Improper Labeling and Storage of Drugs and Biologicals
Penalty
Summary
Drugs and biologicals in the facility were not labeled in accordance with currently accepted professional principles. Additionally, all drugs and biologicals were not stored in locked compartments, and controlled drugs were not kept in separately locked compartments as required. These actions constitute a failure to follow proper labeling and storage protocols for medications and biologicals within the facility.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident’s preferences and goals. This deficiency was identified through surveyor observation and review of records, which showed that care provided did not align with the documented orders or the expressed wishes and care goals of the resident involved.
Failure to Provide Appropriate Mental Health and Psychosocial Services
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident who displayed or was diagnosed with a mental disorder, psychosocial adjustment difficulty, or had a history of trauma and/or post-traumatic stress disorder. The deficiency was identified when it was observed that the resident did not receive the necessary care and interventions to address their mental health or psychosocial needs, as required by their condition and history. This lack of appropriate services and treatment was directly related to the resident's documented mental health diagnosis and trauma history, and the facility did not ensure that individualized care was implemented to support the resident's psychosocial well-being.
Deficient Infection Control Practices in Housekeeping and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in hand hygiene and cleaning protocols by housekeeping staff and improper infection control procedures during urinary catheter care. Housekeeping staff were observed cleaning resident rooms without performing hand hygiene between glove changes or between cleaning different rooms. The housekeeper did not allow the disinfectant solution to remain on surfaces for the full manufacturer-recommended dwell time before wiping, and failed to disinfect high-touch surfaces such as call lights, television remotes, door knobs, and light switches. These actions were not in accordance with both CDC guidelines and the facility's own policies, which require proper hand hygiene and thorough cleaning of high-touch surfaces to prevent the spread of infection. During urinary catheter care for a resident with a suprapubic catheter, the infection preventionist did not perform hand hygiene after assisting the resident to bed and after touching potentially contaminated surfaces, such as the bathroom faucet. The infection preventionist also failed to perform hand hygiene before donning new gloves at multiple points during the procedure, including after removing soiled gloves and before continuing with catheter site care. These actions were inconsistent with CDC recommendations and the facility's policies, which specify that hand hygiene must be performed before and after glove use, and particularly before invasive procedures such as catheter care. Interviews with facility staff, including the maintenance director, assistant director of nursing, and regional director of clinical operations, confirmed that the observed practices did not align with established protocols. Staff acknowledged that hand hygiene should be performed after glove removal and before resident care, and that disinfectant solutions require a specific dwell time to be effective. The failure to follow these procedures was directly observed and documented during the survey, leading to the identified deficiencies in the facility's infection prevention and control program.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to provide culturally competent, trauma-informed care for two residents diagnosed with PTSD. The facility's policy required screening for trauma history upon admission and referral to a mental health professional if trauma-related symptoms were identified. However, the facility did not identify or document the triggers for PTSD in the care plans of the affected residents, nor did they provide individualized interventions to address these issues. Resident #3, a 78-year-old with PTSD and anxiety, was not receiving services for his PTSD despite having a care plan that addressed other mental health concerns such as depression and insomnia. The care plan did not include any person-centered interventions or identification of triggers related to his PTSD. Similarly, Resident #4, a 79-year-old with PTSD, had no care plan addressing his PTSD, and the facility did not determine his PTSD triggers. His care plan focused on depression and medication management but did not acknowledge his PTSD diagnosis. The social service director admitted to not being aware of Resident #4's PTSD diagnosis and acknowledged the lack of a care plan for his PTSD. The director also expressed discomfort in conducting trauma assessments due to not being a licensed social worker and noted the absence of a designated staff member for such assessments. This lack of awareness and appropriate care planning contributed to the deficiency in providing trauma-informed care.
Failure to Provide Adequate Psychosocial Support for Resident with Depression
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with major depressive disorder and aphasia, who exhibited increasing depression and expressed a wish to die. The resident, who was cognitively intact, had a PHQ-9 score indicating mild depression, which increased over time. Despite these indicators, the facility did not update the resident's comprehensive care plan to reflect the worsening depression or the resident's recent statements about wanting to die. The facility's inaction included not providing timely psychosocial support or referring the resident to psychological services until prompted by the resident's family. The care plan inaccurately documented the resident's antidepressant medication, listing Lexapro instead of the prescribed Zoloft. The resident's mood care plan was not revised to address the increased PHQ-9 score or the resident's expressed desire to die, nor did it include any identified behaviors or triggers for depression. Interviews with facility staff revealed that the social services director was unaware of the resident's increasing PHQ-9 scores and confirmed that the care plan had not been updated to reflect the resident's worsening condition. The facility lacked documentation of additional psychosocial support provided to the resident, aside from the delayed referral to psychological services. This deficiency highlights a failure in the facility's responsibility to ensure the resident's mental and psychosocial well-being.
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Illustrative
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 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 | 0.9 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Colorado Springs | 1.1 mi | ★★★★★ | 5 | 1 |
| Medallion Post Acute Rehabilitation | 1.2 mi | ★★★★★ | 0 | 0 |
| Pikes Peak Post Acute | 1.8 mi | ★★★★★ | 2 | 0 |
| Fountain View Rehabilitation And Nursing Llc | 1.9 mi | ★★★★★ | 2 | 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.