Cycle 1
Health 2024-07-31 · Fire 2024-07-31
16 health deficiencies
Top issue: Quality of Life and Care (5 deficiencies)
9 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Colorado Springs, CO
Falcon Heights Rehabilitation And Nursing LLC
2-star overall rating with 2-star inspections with abuse icon flag with $6,146 in total fines with 16 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
1795 Monterey Rd, Colorado Springs, CO
(719) 471-7850
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
107
Certified beds
Average residents
88
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
1982-07-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.62
Registered nurse staffing
LPN hours / resident day
0.48
Licensed practical nurse staffing
Aide hours / resident day
1.84
Nurse aide staffing
Weekend hours
2.43
Weekend nurse staffing
RN turnover
77%
Annual RN turnover
Total nurse turnover
73%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.3
0.4 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.8
0.3 pts better
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 93.1% |
93.5%
0.4 pts worse
|
93.4%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.5% |
94.7%
2.8 pts better
|
95.5%
2 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.3% |
3.4%
0.1 pts better
|
3.3%
About the same
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 16.9% |
7.4%
9.5 pts worse
|
11.4%
5.5 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 1.5% |
5.0%
3.5 pts better
|
5.4%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.3% |
11.2%
0.9 pts better
|
19.6%
9.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 34.3% |
20.6%
13.7 pts worse
|
16.7%
17.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| 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 |
| Percentage of long-stay residents whose ability to walk independently worsened | 15.8% |
15.2%
0.6 pts worse
|
16.3%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 13.2% |
14.6%
1.4 pts better
|
14.9%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.8%
0.4 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.5%
0.1 pts worse
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 15.4% |
22.4%
7 pts better
|
19.8%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 0.7% |
3.7%
3 pts better
|
5.1%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 49.1% |
76.4%
27.3 pts worse
|
81.7%
32.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 9.1% |
1.5%
7.6 pts worse
|
1.6%
7.5 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 64.7% |
75.6%
10.9 pts worse
|
79.7%
15 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-02-22 · Fire 2023-02-22
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
11 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2021-11-18 · Fire 2021-11-18
15 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-07-31
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-08-28
F · Potential for more than minimal harm
2024-07-31
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-08-28
F · Potential for more than minimal harm
2024-07-31
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-10-25
F · Potential for more than minimal harm
2024-07-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-10-18
F · Potential for more than minimal harm
2024-07-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-08-28
F · Potential for more than minimal harm
2024-07-31
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 2024-09-20
E · Potential for more than minimal harm
2024-07-31
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-11-01
D · Potential for more than minimal harm
2024-07-31
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-31
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2024-08-28
F · Potential for more than minimal harm
2023-02-22
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-04-03
F · Potential for more than minimal harm
2023-02-22
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-04-03
F · Potential for more than minimal harm
2023-02-22
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-02-22
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-09-30
F · Potential for more than minimal harm
2023-02-22
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-03
F · Potential for more than minimal harm
2023-02-22
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-04-12
F · Potential for more than minimal harm
2023-02-22
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 2023-04-12
F · Potential for more than minimal harm
2023-02-22
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-13
E · Potential for more than minimal harm
2023-02-22
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-06
D · Potential for more than minimal harm
2023-02-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-04-03
D · Potential for more than minimal harm
2023-02-22
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-03-30
F · Potential for more than minimal harm
2021-11-18
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-06-30
D · Potential for more than minimal harm
2021-11-18
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-18
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-04-08
D · Potential for more than minimal harm
2021-11-18
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2021-12-26
D · Potential for more than minimal harm
2021-11-18
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-01-06
D · Potential for more than minimal harm
2021-11-18
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2021-12-26
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-01
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 2025-12-02
D · Potential for more than minimal harm
2025-02-03
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 2025-02-28
D · Potential for more than minimal harm
2024-09-24
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-10-30
D · Potential for more than minimal harm
2024-09-24
F626 · Resident Rights Deficiencies
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-11-08
G · Actual harm
2024-07-31
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 2024-08-28
F · Potential for more than minimal harm
2024-07-31
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2024-08-28
F · Potential for more than minimal harm
2024-07-31
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 2024-08-28
E · Potential for more than minimal harm
2024-07-31
F555 · Resident Rights Deficiencies
Health
Honor the resident's right to choose his or her attending physician.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-31
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 2024-08-28
E · Potential for more than minimal harm
2024-07-31
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 2024-08-28
E · Potential for more than minimal harm
2024-07-31
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-31
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-08-28
E · Potential for more than minimal harm
2024-07-31
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-31
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 2024-08-28
D · Potential for more than minimal harm
2024-07-31
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 2024-08-28
D · Potential for more than minimal harm
2024-07-31
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-31
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-31
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2024-08-28
D · Potential for more than minimal harm
2024-07-31
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-08-28
D · Potential for more than minimal harm
2023-02-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-03-18
L · Immediate jeopardy
2021-11-18
F886 · Infection Control Deficiencies
Health
Perform COVID19 testing on residents and staff.
Corrected 2021-12-18
G · Actual harm
2021-11-18
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2021-12-18
G · Actual harm
2021-11-18
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2021-12-18
F · Potential for more than minimal harm
2021-11-18
F563 · Resident Rights Deficiencies
Health
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Corrected 2021-12-18
F · Potential for more than minimal harm
2021-11-18
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2021-12-18
F · Potential for more than minimal harm
2021-11-18
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 2021-12-18
F · Potential for more than minimal harm
2021-11-18
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2021-12-18
F · Potential for more than minimal harm
2021-11-18
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2021-12-18
E · Potential for more than minimal harm
2021-11-18
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2021-12-18
E · Potential for more than minimal harm
2021-11-18
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2021-12-18
D · Potential for more than minimal harm
2021-11-18
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2021-12-18
D · Potential for more than minimal harm
2021-11-18
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2021-12-18
D · Potential for more than minimal harm
2021-11-18
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 2021-12-18
D · Potential for more than minimal harm
2021-11-18
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2021-12-18
D · Potential for more than minimal harm
2021-11-18
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2021-12-18
Penalties and ownership
What sits behind the stars
$6,146
2024-09-24
Fine
Fine · fine $6,146
Fine
Ownership
Maze Family Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Charly Bello Family Limited Partnership
5% Or Greater Direct Ownership Interest · Organization
Myers, Walter
5% Or Greater Indirect Ownership Interest · Individual
Myers, Katie
5% Or Greater Indirect Ownership Interest · Individual
Swain, Jared
5% Or Greater Indirect Ownership Interest · Individual
Swain, Holly
5% Or Greater Indirect Ownership Interest · Individual
Mahrt, David
5% Or Greater Indirect Ownership Interest · Individual
Pickd LLC
5% Or Greater Direct Ownership Interest · Organization
Abbott, Ian
Operational/Managerial Control · Individual
Cottonwood Healthcare LLC
Operational/Managerial Control · Organization
Holmes, Carolyn
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Fountain View Rehabilitation And Nursing LLC
Colorado Springs, CO
1-star overall rating with 2-star inspections with $12,968 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Life Care Center Of Colorado Springs
Colorado Springs, CO
5-star overall rating with 4-star inspections with 3 recent health deficiencies
#3
Advanced Health Care Of Colorado Springs
Colorado Springs, CO
5-star overall rating with 5-star inspections with 13 fire-safety deficiencies in the latest cycle
Jump out
Supporting pages
City page
Best nursing homes in Colorado Springs, CO
See how this facility ranks inside its city.
20 facilitiesCounty
El Paso County
County ranking page for nearby alternatives.
20 facilitiesChain
The Charly Bello Family, The Maze Family, The Swain Family, & Walter Myers
Chain page for the operating group.
18 facilities