15 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Colorado Springs, CO
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
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
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
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
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
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
| 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
| 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
Top issue: Quality of Life and Care (10 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Nutrition and Dietary (4 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
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
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-21
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-11-30
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-31
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-21
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-21
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2023-10-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-21
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-19
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-21
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2019-11-25
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2019-12-02
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2019-01-22
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
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
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
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-12-22
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-21
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-08-21
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
Health
Provide activities to meet all resident's needs.
Corrected 2025-08-21
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-08-21
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-08-21
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-21
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
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
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
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2025-08-21
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-08-21
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-21
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2024-10-25
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-09-01
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-11-08
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
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
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
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-09-01
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-17
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
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
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2019-11-27
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
Health
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Corrected 2019-11-27
Health
Provide care by qualified persons according to each resident's written plan of care.
Corrected 2019-11-27
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
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2019-11-27
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2019-11-27
Health
Assess the resident when there is a significant change in condition
Corrected 2019-11-27
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2019-11-27
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2019-11-27
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2019-11-27
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2019-11-27
Health
Provide and implement an infection prevention and control program.
Corrected 2019-11-27
Penalties and ownership
Fine · fine $24,453
Fine
Payment Denial · denial start 2023-09-29 · 40 days
40 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Indirect Ownership Interest · Individual
5% Or Greater Direct Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Nearby options
Colorado Springs, CO
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
Colorado Springs, CO
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
Colorado Springs, CO
3-star overall rating with 3-star inspections with 6 recent health deficiencies
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