Colorado Springs, CO

Colonial Rehabilitation And Nursing, LLC

1-star overall rating with 2-star inspections with abuse icon flag with $24,453 in total fines with 15 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle

1340 E Fillmore St, Colorado Springs, CO

(719) 473-1105

Compare this facility

Overall

1 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

3 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

80

Certified beds

Average residents

74

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

The Charly Bello Family, The Maze Family, The Swain Family, & Walter Myers

Operator or chain grouping

Approved since

1985-12-01

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

18 facilities

Chain averages 2 overall / 2 health / 2 staffing / 3 quality stars

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.36

Registered nurse staffing · state 0.83 · national 0.68

LPN hours / resident day

0.79

Licensed practical nurse staffing · state 0.68 · national 0.87

Aide hours / resident day

2.05

Nurse aide staffing · state 2.20 · national 2.35

Total nurse hours

3.20

All reported nurse hours · state 3.70 · national 3.89

Licensed hours

1.15

RN + LPN hours · state 1.51 · national 1.54

Weekend hours

2.90

Weekend nurse staffing · state 3.26 · national 3.43

Weekend RN hours

0.28

Weekend registered nurse coverage · state 0.60 · national 0.47

Physical therapist

0.05

Reported PT staffing · state 0.09 · national 0.07

Adjusted RN hours

0.41

CMS adjusted RN staffing hours

Adjusted total hours

3.66

CMS adjusted total nurse staffing hours

Case-mix index

1.20

Higher values indicate more complex resident acuity

RN turnover

88%

Annual RN turnover · state 46% · national 45%

Total nurse turnover

71%

Annual nurse turnover · state 49% · national 46%

SNF VBP

Value-based purchasing

Program rank

12,530

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

11.81

Composite VBP score used to determine payment impact.

Payment multiplier

0.9810

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

0

Baseline 72.46% · Performance 100.00% · Measure score 0 · Achievement 0 · Improvement 0

Adjusted total nurse staffing

2.36

Baseline 3.89 hours · Performance 3.75 hours · Measure score 2.36 · Achievement 2.36 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure Facility National Note
Potentially preventable 30-day readmission Not Available
10.72%
Not Available · Eligible stays 15 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community Not Available
50.57%
Not Available · Eligible stays 5 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary Not Available
1.02
Too few residents or stays to report publicly.
Drug regimen review with follow-up Not Available
95.27%
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Falls with major injury Not Available
0.77%
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Discharge self-care score Not Available
53.69%
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Discharge mobility score Not Available
50.94%
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened Not Available
2.29%
Numerator Not Available · Denominator 10 · Adjusted rate Not Available · Too few residents or stays to report publicly.
Healthcare-associated infections requiring hospitalization Not Available
7.12%
Not Available · Eligible stays 3 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage 7.58%
8.2%
0.6 pts worse
Numerator 10 · Denominator 132
Staff flu vaccination coverage 87.34%
42%
45.3 pts better
Numerator 69 · Denominator 79
Discharge function score Not Available
56.45%
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly.
Transfer of health information to provider Not Available
95.95%
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly.
Transfer of health information to patient Not Available
96.28%
Numerator Not Available · Denominator Not Available · Newly certified or not enough cases to report.
Resident COVID-19 vaccinations up to date Not Available
25.2%
Numerator Not Available · Denominator 8 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure Facility State National Note
Number of hospitalizations per 1000 long-stay resident days 2.4
1.3
1.1 pts worse
1.9
0.5 pts worse
Long Stay · 20240701-20250630 · Adjusted 2.4 · Observed 1.5 · Expected 1.2 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days 0.9
1.7
0.8 pts better
1.8
0.9 pts better
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 0.7 · Expected 1.3 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine 93.5%
93.5%
About the same
93.4%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 89.4% · Q2 92.5% · Q3 97.1% · Q4 94.7% · 4Q avg 93.5%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine 93.1%
94.7%
1.6 pts worse
95.5%
2.4 pts worse
Long Stay · 2024Q3-2025Q2 · 4Q avg 93.1%
Percentage of long-stay residents experiencing one or more falls with major injury 4.0%
3.4%
0.6 pts worse
3.3%
0.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.0% · Q3 5.7% · Q4 5.3% · 4Q avg 4.0% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms 12.2%
7.4%
4.8 pts worse
11.4%
0.8 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 11.7% · Q2 14.0% · Q3 13.8% · Q4 9.5% · 4Q avg 12.2%
Percentage of long-stay residents who lose too much weight 6.4%
5.0%
1.4 pts worse
5.4%
1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 7.7% · Q2 3.4% · Q3 5.2% · Q4 9.1% · 4Q avg 6.4%
Percentage of long-stay residents who received an antianxiety or hypnotic medication 16.7%
11.2%
5.5 pts worse
19.6%
2.9 pts better
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 17.5% · Q3 15.0% · Q4 14.9% · 4Q avg 16.7%
Percentage of long-stay residents who received an antipsychotic medication 31.8%
20.6%
11.2 pts worse
16.7%
15.1 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 41.5% · Q2 33.3% · Q3 21.4% · Q4 31.2% · 4Q avg 31.8% · Used in QM five-star
Percentage of long-stay residents who were physically restrained 0.0%
0.1%
0.1 pts better
0.1%
0.1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened 23.6%
15.2%
8.4 pts worse
16.3%
7.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 43.3% · Q2 26.5% · Q3 12.9% · Q4 14.4% · 4Q avg 23.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased 19.2%
14.6%
4.6 pts worse
14.9%
4.3 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q2 17.3% · Q3 16.9% · Q4 18.2% · 4Q avg 19.2% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder 0.0%
0.8%
0.8 pts better
1.0%
1 pts better
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection 1.1%
1.5%
0.4 pts better
1.7%
0.6 pts better
Long Stay · 2024Q4-2025Q3 · Q1 1.6% · Q2 0.0% · Q3 0.0% · Q4 2.7% · 4Q avg 1.1% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence 22.5%
22.4%
0.1 pts worse
19.8%
2.7 pts worse
Long Stay · 2024Q4-2025Q3 · Q1 32.1% · Q2 21.7% · Q3 21.1% · Q4 16.5% · 4Q avg 22.5%
Percentage of long-stay residents with pressure ulcers 3.7%
3.7%
About the same
5.1%
1.4 pts better
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 4.2% · Q3 2.7% · Q4 2.7% · 4Q avg 3.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine 61.7%
76.4%
14.7 pts worse
81.7%
20 pts worse
Short Stay · 2024Q4-2025Q3 · 4Q avg 61.7%

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-07-24 · Fire 2023-08-31

15 health deficiencies

Top issue: Quality of Life and Care (10 deficiencies)

9 fire-safety deficiencies

Top issue: Smoke (4 deficiencies)

Cycle 2 Health 2023-08-31 · Fire 2019-10-16

9 health deficiencies

Top issue: Nutrition and Dietary (4 deficiencies)

2 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Cycle 3 Health 2019-10-16 · Fire 2018-11-15

14 health deficiencies

Top issue: Quality of Life and Care (4 deficiencies)

3 fire-safety deficiencies

Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2023-08-31

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2023-10-21

F · Potential for more than minimal harm 2023-08-31

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2023-11-30

F · Potential for more than minimal harm 2023-08-31

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2023-08-31

F · Potential for more than minimal harm 2023-08-31

K521 · Services Deficiencies

Fire Safety

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Corrected 2023-10-21

F · Potential for more than minimal harm 2023-08-31

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-10-21

F · Potential for more than minimal harm 2023-08-31

K917 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure electrical receptacles or cover plates have distinctive color or marking.

Corrected 2023-10-21

F · Potential for more than minimal harm 2023-08-31

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-10-21

D · Potential for more than minimal harm 2023-08-31

K211 · Egress Deficiencies

Fire Safety

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Corrected 2024-03-19

D · Potential for more than minimal harm 2023-08-31

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-10-21

F · Potential for more than minimal harm 2019-10-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2019-11-25

E · Potential for more than minimal harm 2019-10-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2019-12-02

F · Potential for more than minimal harm 2018-11-15

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2019-01-22

D · Potential for more than minimal harm 2018-11-15

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2019-01-22

D · Potential for more than minimal harm 2018-11-15

K914 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Corrected 2019-01-22

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-04

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-12-22

D · Potential for more than minimal harm 2025-12-04

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-12-22

G · Actual harm 2025-07-24

F684 · Quality of Life and Care Deficiencies

Health

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Corrected 2025-08-21

G · Actual harm 2025-07-24

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-08-21

E · Potential for more than minimal harm 2025-07-24

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2025-08-21

E · Potential for more than minimal harm 2025-07-24

F679 · Quality of Life and Care Deficiencies

Health

Provide activities to meet all resident's needs.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-07-24

F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-07-24

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-07-24

F686 · Quality of Life and Care Deficiencies

Health

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-07-24

F688 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-07-24

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-07-24

F693 · Quality of Life and Care Deficiencies

Health

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-07-24

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-07-24

F757 · Pharmacy Service Deficiencies

Health

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Corrected 2025-08-21

D · Potential for more than minimal harm 2025-07-24

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-08-21

E · Potential for more than minimal harm 2024-10-17

F555 · Resident Rights Deficiencies

Health

Honor the resident's right to choose his or her attending physician.

Corrected 2024-10-25

G · Actual harm 2023-08-31

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-09-01

F · Potential for more than minimal harm 2023-08-31

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2023-11-08

E · Potential for more than minimal harm 2023-08-31

F803 · Nutrition and Dietary Deficiencies

Health

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Corrected 2023-09-01

E · Potential for more than minimal harm 2023-08-31

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-09-01

D · Potential for more than minimal harm 2023-08-31

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2023-09-01

D · Potential for more than minimal harm 2023-08-31

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2023-09-01

D · Potential for more than minimal harm 2023-08-31

F760 · Pharmacy Service Deficiencies

Health

Ensure that residents are free from significant medication errors.

Corrected 2023-10-17

D · Potential for more than minimal harm 2023-08-31

F808 · Nutrition and Dietary Deficiencies

Health

Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.

Corrected 2023-09-01

F · Potential for more than minimal harm 2019-10-16

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2019-11-17

E · Potential for more than minimal harm 2019-10-16

F550 · Resident Rights Deficiencies

Health

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Corrected 2019-11-27

E · Potential for more than minimal harm 2019-10-16

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2019-11-27

E · Potential for more than minimal harm 2019-10-16

F604 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Corrected 2019-11-27

E · Potential for more than minimal harm 2019-10-16

F659 · Resident Assessment and Care Planning Deficiencies

Health

Provide care by qualified persons according to each resident's written plan of care.

Corrected 2019-11-27

E · Potential for more than minimal harm 2019-10-16

F726 · Nursing and Physician Services Deficiencies

Health

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Corrected 2019-11-27

E · Potential for more than minimal harm 2019-10-16

F759 · Pharmacy Service Deficiencies

Health

Ensure medication error rates are not 5 percent or greater.

Corrected 2019-11-27

E · Potential for more than minimal harm 2019-10-16

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2019-11-27

D · Potential for more than minimal harm 2019-10-16

F637 · Resident Assessment and Care Planning Deficiencies

Health

Assess the resident when there is a significant change in condition

Corrected 2019-11-27

D · Potential for more than minimal harm 2019-10-16

F676 · Quality of Life and Care Deficiencies

Health

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Corrected 2019-11-27

D · Potential for more than minimal harm 2019-10-16

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2019-11-27

D · Potential for more than minimal harm 2019-10-16

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2019-11-27

D · Potential for more than minimal harm 2019-10-16

F744 · Quality of Life and Care Deficiencies

Health

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Corrected 2019-11-27

D · Potential for more than minimal harm 2019-10-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2019-11-27

Penalties and ownership

What sits behind the stars

$24,453 2023-08-31

Fine

Fine · fine $24,453

Fine

$0 2023-08-31

Payment Denial

Payment Denial · denial start 2023-09-29 · 40 days

40 day denial

Ownership

Maze Family Limited Partnership

5% Or Greater Direct Ownership Interest · Organization

50% 18 facilities 2024-09-01
Charly Bello Family Limited Partnership

5% Or Greater Direct Ownership Interest · Organization

40% 18 facilities 2024-09-01
Myers, Walter

5% Or Greater Indirect Ownership Interest · Individual

25% 23 facilities 2024-09-01
Myers, Katie

5% Or Greater Indirect Ownership Interest · Individual

24% 16 facilities 2024-09-01
Swain, Jared

5% Or Greater Indirect Ownership Interest · Individual

20% 21 facilities 2024-09-01
Swain, Holly

5% Or Greater Indirect Ownership Interest · Individual

19% 16 facilities 2024-09-01
Mahrt, David

5% Or Greater Indirect Ownership Interest · Individual

10% 13 facilities 2024-09-01
Pickd LLC

5% Or Greater Direct Ownership Interest · Organization

10% 13 facilities 2024-09-01
Cottonwood Healthcare LLC

Operational/Managerial Control · Organization

0% 16 facilities 2024-09-01
Turley, Ryan

Operational/Managerial Control · Individual

0% 1 facilities 2024-09-01

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1-star overall rating with 1-star inspections with abuse icon flag with $89,318 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

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Staffing
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Fines
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2-star overall rating with 2-star inspections with $26,845 in total fines with 10 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle

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Staffing
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Fines
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#3

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Overall
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Health
3 / 5
Staffing
2 / 5
Fines
$0

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