Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 The Healthcare Resort Of Colorado Springs during CMS and state inspections, most recent first.
Surveyors observed improper thawing of raw chicken in the kitchen, with the meat not consistently under running water as required by regulations and facility policy. Additionally, a cook was seen wearing a watch, a non-removable bracelet, and multiple rings during food preparation and service, with one ring falling onto the tray line near food. These actions did not comply with sanitary standards for food handling.
Residents were not consistently given the option to dine in the main dining room during dinner and on weekends, despite expressing a preference for this setting to socialize and enjoy meals with others. Staff interviews and observations confirmed that the dining room was only open for breakfast and lunch, and that residents were often required to eat in their rooms or at tables near the nursing stations due to staffing limitations and lack of supervision. This practice did not align with facility policy or communicated meal times, resulting in a failure to support resident self-determination and choice.
Surveyors found that medications and vaccines were not stored or labeled according to professional standards. Vaccines were kept in a dormitory-style refrigerator without temperature monitoring, and expired vaccines and an undated Tubersol vial were present. Medication carts contained loose pills, creams stored with inhalers, and topical patches not in original packaging. Staff interviews confirmed these practices did not meet facility policy.
Two residents who required assistance with bathing did not receive the necessary services as outlined in their care plans. One resident, dependent due to quadriplegia, did not receive any documented baths or showers for an extended period, while another, recovering from a hip fracture, was left to shower independently despite needing supervision or touch assistance. Staff did not follow the specified care plans, and documentation did not reflect the required level of care.
A resident with a strong preference for group activities and socialization did not have access to group activities on weekends, as the facility's weekend schedule primarily offered independent activities and minimal staff-facilitated group events. The resident reported feeling isolated, and staff confirmed that group activities were not consistently provided on weekends, contrary to facility policy.
Two residents with respiratory conditions were observed receiving higher oxygen flow rates than ordered by their physicians. Despite care plans and physician orders specifying maximum LPM for oxygen therapy, both residents were administered more than prescribed. Staff interviews confirmed that the incorrect flow rates were not identified or corrected during routine checks, and documentation of actual oxygen delivery was lacking.
A medication error rate above 5% was identified when an LPN dispensed an incorrect dose of meloxicam and a CNA-Med inaccurately measured Voltaren gel without using the manufacturer's dosing card, both contrary to physician orders and facility policy. These errors were confirmed through observation and staff interviews, highlighting failures to follow the seven rights of medication administration.
A resident with a history of diabetes and urinary issues experienced a delay in diagnosis and treatment of a UTI after a urine sample was sent to the lab without proper labeling, resulting in the test not being processed. Despite ongoing symptoms and repeated requests for pain medication, there was no timely follow-up with the lab or physician, and a second sample was not collected for several days. Staff interviews revealed confusion and lack of documentation regarding the delay and the need for recollection.
Two residents receiving hospice services did not have their care plans updated to reflect hospice involvement, and hospice documentation was not accessible to facility staff. Staff were aware of hospice services but could not locate care plans or documentation, and communication between the facility and hospice provider was limited to verbal reports, with no written records in the residents' charts.
Failure to Maintain Sanitary Food Preparation and Service Conditions
Penalty
Summary
The facility failed to ensure that food was prepared, distributed, and served under sanitary conditions in the main kitchen. During a continuous observation of lunch meal service, three bags of raw frozen chicken cutlets were observed being thawed in the kitchen sink without running water, contrary to both state regulations and facility policy, which require thawing under running water with sufficient velocity to agitate and float off loose particles. The chicken cutlets remained in their original packaging and were not consistently submerged or exposed to running water throughout the observed period. At times, the water was off, only trickling, or not covering the entire surface of the chicken, and at one point, the sink overflowed onto the floor. Eventually, the chicken was removed and placed in the walk-in refrigerator, but the thawing process did not adhere to required safe practices during the observed period. Additionally, the facility failed to ensure that dietary staff did not wear inappropriate jewelry during food preparation and service. The cook was observed wearing a watch, a fashion dangly chain bracelet, and two plain band rings while preparing and plating meals. During the meal service, one of the rings fell off onto the tray line near food, and the cook picked it up and placed it in his pocket before continuing to plate food. Both the dietary manager and the regional dietary consultant acknowledged that only a plain wedding band should be worn, and that the observed bracelet could not be removed. The dietary staff had been provided education on jewelry policies, but the observed practices did not comply with facility policy or state regulations. No specific residents or patients were directly involved or affected in the events described, and the report does not mention any medical history or conditions related to residents at the time of the deficiency. The deficiencies were identified through direct observation of staff practices and interviews with dietary management.
Failure to Honor Resident Choice for Dining Room Use at Dinner and Weekends
Penalty
Summary
The facility failed to honor resident choices regarding dining location, specifically by not ensuring that residents could choose to eat in the main dining room during dinner and on weekends. Multiple residents reported that the dining room was only open for breakfast and lunch, and that they were required to eat dinner in their rooms or at tables near the nursing stations. Residents expressed a preference for dining in the main dining room to socialize and enjoy meals with peers, but stated that this option was not available to them for dinner or on weekends. Staff interviews confirmed that the main dining room was not consistently open for dinner due to staffing limitations, and that residents were not always invited or informed about the option to dine in the main dining room during these times. Observations during meal times corroborated resident and staff statements, as the dining room was found to be empty during scheduled dinner service, with residents waiting for their meals in their rooms. Family members and resident representatives also attempted to use the dining room for dinner but were told by staff that it was not open due to lack of supervision. Despite facility policies stating that residents have the right to make choices about significant aspects of their lives, including dining preferences, and documentation indicating that the dining room was supposed to be open for all meals, the practice did not align with these policies. Record review showed that staff had been educated about the reopening of the dining room and that meal times were communicated as being available in the dining room. However, interviews with staff revealed ongoing confusion and inconsistent knowledge about dining room availability, particularly for dinner and weekends. The deficiency was further evidenced by the lack of consistent communication to residents about their dining options and the failure to accommodate resident preferences as outlined in facility policy.
Deficient Storage and Labeling of Medications and Vaccines
Penalty
Summary
Surveyors identified multiple deficiencies in the facility's storage and labeling of medications and biologicals. Vaccines were found stored in a dormitory-style refrigerator, which is not approved for vaccine storage according to CDC guidelines. The refrigerator lacked a thermometer for temperature monitoring, and staff were unaware that such a refrigerator was inappropriate for vaccine storage. Expired vaccines, including COVID-19, Prevnar 20, and Influenza vaccines, were present in the refrigerator, and a vial of Tubersol was found without an open date, contrary to manufacturer instructions that require discarding after 30 days of use. Medication carts were also found to be noncompliant with professional standards and facility policy. Creams and ointments were stored together with inhalers and nasal sprays, rather than being separated by route of administration. Loose pills and capsules were found in the medication drawers, and topical lidocaine patches were not kept in their original packaging, which could compromise their effectiveness. Staff interviews confirmed that these storage practices did not align with facility policy or professional standards. The facility's policies require medications and biologicals to be stored securely, labeled properly, and separated by route of administration. Outdated or improperly stored medications are to be removed immediately, and temperature monitoring for refrigerated items is mandated. However, observations and staff interviews revealed that these procedures were not consistently followed, resulting in the deficiencies cited.
Failure to Provide Required Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with bathing and personal hygiene for two residents who were unable to perform activities of daily living (ADLs) independently. One resident, who was quadriplegic and dependent on staff for all ADLs, did not receive any documented baths or showers for a period of 20 days following admission, despite being scheduled for bed baths twice weekly. The resident reported not receiving showers due to the lack of an appropriate shower chair, and staff confirmed that spa shower rooms were unavailable as they were being used for other purposes. The resident's care plan and Kardex indicated a need for substantial or maximal assistance with bathing, but there was no evidence this care was provided. Another resident, admitted with a hip fracture and difficulty walking, required supervision or touching assistance with bathing according to her care plan and Kardex. However, staff only provided setup assistance, leaving the resident to shower independently despite her recent fall and mobility limitations. The resident reported that staff did not offer showers as scheduled and that she was left alone during bathing, contrary to her care plan requirements. Documentation in the electronic medical record reflected only setup assistance, not the required level of supervision or physical help. Interviews with CNAs and nursing staff revealed inconsistencies in understanding and following the residents' care plans and assistance levels. Staff relied on various sources for information, such as white boards, paper reports, and the EMR, but did not consistently provide the level of care specified in the residents' plans. The DON acknowledged the lack of documentation for one resident's bathing and recognized that staff were not providing the required supervision for the other resident. The facility's failure to ensure that residents received the necessary services for bathing and personal hygiene resulted in unmet care needs for both individuals.
Failure to Provide Group Activities on Weekends
Penalty
Summary
The facility failed to provide an ongoing program of activities designed to meet the needs and interests of one resident, who was cognitively intact and expressed a strong preference for group activities and socialization. Despite the resident's care plan and MDS assessment indicating the importance of group activities, the weekend activity schedule primarily consisted of independent activities, with only a non-denominational church service and 'coffee and news' as potential group options. The resident reported feeling isolated on weekends, with little opportunity for group interaction, and stated that she had to rely on her husband to bring entertainment from home due to the lack of engaging activities. Staff interviews confirmed that the activities director only worked weekdays and that weekend activities were largely independent, with minimal staff involvement in facilitating group events. The receptionist, who was listed as assisting with weekend activities, stated that her responsibilities did not include activity facilitation. The facility's policy required daily activities, including weekends, to be provided according to resident preferences, but observations and interviews revealed that this was not being met for the resident in question.
Failure to Administer Oxygen Therapy as Ordered by Physician
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for two residents who were receiving oxygen therapy. Both residents had physician orders specifying the maximum liters per minute (LPM) of oxygen to be administered, but observations revealed that each was receiving a higher LPM than ordered. For one resident with diagnoses including COPD and respiratory failure, the physician's order specified up to 4 LPM of oxygen via nasal cannula, but the resident was observed on multiple occasions receiving 5 LPM. The resident's care plan and medical record did not document the actual LPM being administered, and the resident was unaware of the current setting. For the second resident, who also had COPD and respiratory failure, the physician's order specified up to 5 LPM of oxygen, but the resident was observed receiving 6 LPM on several occasions. The care plan referenced a high flow nasal cannula up to 10 LPM, but the physician's order in effect was for 5 LPM. The resident reported believing she was receiving the correct amount, and her oxygen saturation levels were documented as being within the target range. Interviews with staff revealed that CNAs were not permitted to change oxygen flow rates and relied on nurses for communication regarding changes. However, the LPN on duty confirmed that both residents were on incorrect oxygen flow rates and admitted not checking the settings during morning rounds. The DON also confirmed that physician orders for oxygen were not being followed, as oxygen is considered a form of medication and must be administered as prescribed.
Medication Error Rate Exceeds Acceptable Threshold Due to Incorrect Dosing
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, as required by professional standards and facility policy. During the survey, two medication errors were identified out of 28 opportunities, resulting in a 7.14% error rate. The first error involved an LPN who prepared and dispensed a full 7.5 mg tablet of meloxicam for a resident, despite the physician's order specifying that only half a tablet (3.75 mg) should be administered. The error was only corrected after prompting, indicating a lapse in following the correct medication administration procedure. The second error involved a CNA-Med who dispensed Voltaren gel for a resident by measuring it directly into a medication cup, rather than using the manufacturer's dosing card as specified in the physician's order and the product's instructions. The CNA-Med incorrectly equated milliliters to grams and was unsure of the proper dispensing method. Upon review, it was found that the amount dispensed using the medication cup exceeded the correct dose as measured by the dosing card, confirming the error in administration. Interviews with the DON and the facility pharmacist confirmed that staff are expected to follow the seven rights of medication administration and use appropriate tools, such as dosing cards, to ensure accurate dosing. Both staff members involved failed to adhere to these standards, resulting in the administration of incorrect medication doses to residents.
Failure to Provide Timely Laboratory Services Due to Unlabeled Urine Sample and Lack of Follow-Up
Penalty
Summary
The facility failed to provide timely laboratory services as ordered by a physician for one resident, resulting in a delay in diagnosis and treatment of a urinary tract infection (UTI). The resident, who had a history of diabetes, COPD, and benign prostatic hyperplasia, began experiencing symptoms of a UTI, including dysuria, cloudy urine, and urinary frequency. A urinalysis with culture and sensitivity was ordered, and a urine sample was collected and sent to the laboratory. However, the sample was not labeled with the resident's identifying information, and the laboratory did not process the test as a result. Despite the resident's ongoing symptoms and repeated requests for pain medication, there was no documentation that the facility followed up with the laboratory or the physician regarding the missing urinalysis results for several days. The resident continued to experience pain and discomfort, and a second urine sample was not collected until four days after the initial sample was sent. The facility's records did not indicate the reason for the delay or the need for a second urinalysis, nor was there documentation of any attempts to recollect the sample prior to the second collection. Interviews with staff revealed confusion and lack of awareness regarding the resident's urinary issues and the status of the laboratory tests. The DON, ADON, and other staff members were unable to provide clear explanations for the delay or confirm whether the laboratory had been contacted after the initial sample was found to be unlabeled. The facility's failure to ensure proper labeling, timely follow-up, and clear documentation resulted in a significant delay in providing necessary laboratory services to meet the resident's needs.
Failure to Update Hospice Care Plans and Ensure Accessible Documentation
Penalty
Summary
The facility failed to ensure that hospice services provided to two residents met professional standards and principles, specifically in the areas of care plan updates and documentation accessibility. For one resident with chronic obstructive pulmonary disease (COPD) and other comorbidities, the care plan was not updated to reflect the initiation of hospice services. The care plan lacked delineation of responsibilities between the facility and the hospice provider, and staff interviews revealed a lack of awareness regarding the resident's hospice care goals and the location of hospice documentation. Despite staff knowing the resident was on hospice, the comprehensive care plan did not include hospice interventions or coordination details. For another resident with dementia and other diagnoses, the facility did not ensure that hospice agency notes regarding care were easily accessible to facility staff. Although the resident was admitted to hospice services, the hospice binder and electronic medical record (EMR) did not contain documentation from hospice nursing staff about their visits and care provided, except for a single social worker visit. Staff reported that hospice staff verbally communicated care provided, but there was no written documentation in the resident's records. The lack of accessible documentation hindered effective coordination of care between the facility and hospice agency. Facility policy required that a care plan be developed upon admission to hospice and that hospice services be integrated into the individualized, interdisciplinary care plan. The contract with the hospice provider also stipulated the need for communication and documentation in the resident's medical chart. However, these requirements were not met, as evidenced by the absence of updated care plans and accessible hospice documentation for the residents reviewed.
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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) |
|---|---|---|---|---|
| Center At Centennial, The | 0.8 mi | ★★★★★ | 0 | 0 |
| Springs Village Care Center | 1.1 mi | ★★★★★ | 1 | 0 |
| Gardens, The | 1.9 mi | ★★★★★ | 12 | 0 |
| Sundance Skilled Nursing And Rehabilitation | 2 mi | ★★★★★ | 22 | 1 |
| Bear Creek Senior Living | 2.5 mi | ★★★★★ | 1 | 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.