Cycle 1
Health 2025-06-26 · Fire 2025-06-26
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Colorado Springs, CO
Healthcare Resort Of Colorado Springs, The
3-star overall rating with 2-star inspections with $79,098 in total fines with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
2818 Grand Vista Cir, Colorado Springs, CO
(719) 632-7000
Overall
3 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
97
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2016-08-12
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 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
0.92
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.99
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.61
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
4.52
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.91
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
3.83
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.49
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.24
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.87
CMS adjusted RN staffing hours
Adjusted total hours
4.26
CMS adjusted total nurse staffing hours
Case-mix index
1.45
Higher values indicate more complex resident acuity
RN turnover
33%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
9,171
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
24.57
Composite VBP score used to determine payment impact.
Payment multiplier
0.9835
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.10% · Performance 24.02% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.99% · Performance 7.81% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.08
Baseline 45.74% · Performance 51.08% · Measure score 3.08 · Achievement 3.08 · Improvement 0
Adjusted total nurse staffing
6.75
Baseline 4.64 hours · Performance 5 hours · Measure score 6.75 · Achievement 6.75 · Improvement 2.66
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.09% |
10.72%
1.6 pts better
|
No Different than the National Rate · Eligible stays 387 · Observed rate 7.24% · Lower 95% interval 6.22% |
| Discharge to community | 62.72% |
50.57%
12.1 pts better
|
Better than the National Rate · Eligible stays 419 · Observed rate 60.38% · Lower 95% interval 58.6% |
| Medicare spending per beneficiary | 1.06 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 94.29% |
95.27%
1 pts worse
|
Numerator 264 · Denominator 280 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 280 |
| Discharge self-care score | 62.93% |
53.69%
9.2 pts better
|
Numerator 129 · Denominator 205 |
| Discharge mobility score | 68.78% |
50.94%
17.8 pts better
|
Numerator 141 · Denominator 205 |
| Pressure ulcers or injuries, new or worsened | 0.36% |
2.29%
1.9 pts better
|
Numerator 1 · Denominator 280 · Adjusted rate 0.47% |
| Healthcare-associated infections requiring hospitalization | 7.81% |
7.12%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 309 · Observed rate 7.12% · Lower 95% interval 5.3% |
| Staff COVID-19 vaccination coverage | 1.33% |
8.2%
6.9 pts worse
|
Numerator 3 · Denominator 226 |
| Staff flu vaccination coverage | 80.81% |
42%
38.8 pts better
|
Numerator 219 · Denominator 271 |
| Discharge function score | 71.71% |
56.45%
15.3 pts better
|
Numerator 147 · Denominator 205 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 81 · Denominator 81 |
| Transfer of health information to patient | 97.91% |
96.28%
1.6 pts better
|
Numerator 187 · Denominator 191 |
| Resident COVID-19 vaccinations up to date | 12.14% |
25.2%
13.1 pts worse
|
Numerator 17 · Denominator 140 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
93.5%
6.5 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 68.2% |
94.7%
26.5 pts worse
|
95.5%
27.3 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 68.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.4%
3.4 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 13.9% |
7.4%
6.5 pts worse
|
11.4%
2.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.0% · Q4 0.0% · 4Q avg 13.9% |
| Percentage of long-stay residents who lose too much weight | 8.0% |
5.0%
3 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.0% · Q4 9.5% · 4Q avg 8.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
11.2%
10.6 pts worse
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.0% · Q4 22.7% · 4Q avg 21.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.2% |
20.6%
0.6 pts worse
|
16.7%
4.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 21.2% · 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% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.7% |
15.2%
7.5 pts better
|
16.3%
8.6 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 7.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 2.7% |
14.6%
11.9 pts better
|
14.9%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 0.0% · 4Q avg 2.7% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.2% |
0.8%
0.4 pts worse
|
1.0%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 4.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
1.5%
0.3 pts better
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
22.4%
1.4 pts better
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 14.0% · Q4 28.6% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 1.2% |
3.7%
2.5 pts better
|
5.1%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 4.2% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 89.9% |
76.4%
13.5 pts better
|
81.7%
8.2 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.0% · Q2 91.1% · Q3 91.1% · Q4 87.3% · 4Q avg 89.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 17.0% |
12.8%
4.2 pts worse
|
12.0%
5 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 17.0% · Observed 16.0% · Expected 10.5% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.5%
0.9 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.9% · Q2 0.6% · Q3 0.6% · Q4 0.3% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 75.7% |
75.6%
0.1 pts better
|
79.7%
4 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 75.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
20.3%
4.7 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 25.0% · Expected 23.8% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-08 · Fire 2023-11-08
9 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Cycle 3
Health 2022-07-27 · Fire 2022-07-27
3 health deficiencies
Top issue: Pharmacy Service (1 deficiency)
1 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
2025-06-26
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-06-26
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-09-22
F · Potential for more than minimal harm
2025-06-26
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 2025-09-22
D · Potential for more than minimal harm
2025-06-26
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 2025-09-22
F · Potential for more than minimal harm
2023-11-08
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-12-26
F · Potential for more than minimal harm
2023-11-08
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-12-26
D · Potential for more than minimal harm
2022-07-27
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-09-27
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-06-26
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 2025-07-16
E · Potential for more than minimal harm
2025-06-26
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2025-07-16
E · Potential for more than minimal harm
2025-06-26
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 2025-07-16
D · Potential for more than minimal harm
2025-06-26
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 2025-07-16
D · Potential for more than minimal harm
2025-06-26
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-26
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-26
F770 · Administration Deficiencies
Health
Provide timely, quality laboratory services/tests to meet the needs of residents.
Corrected 2025-07-16
D · Potential for more than minimal harm
2025-06-26
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2025-07-16
K · Immediate jeopardy
2023-11-08
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 2023-12-07
E · Potential for more than minimal harm
2023-11-08
F574 · Resident Rights Deficiencies
Health
The resident has the right to receive notices in a format and a language he or she understands.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-08
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-08
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 2023-12-07
E · Potential for more than minimal harm
2023-11-08
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-08
F867 · Administration Deficiencies
Health
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-07
E · Potential for more than minimal harm
2023-11-08
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-12-07
C · Minimal harm
2023-11-08
F577 · Resident Rights Deficiencies
Health
Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.
Corrected 2023-12-07
D · Potential for more than minimal harm
2022-07-27
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-07-27
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-22
D · Potential for more than minimal harm
2022-07-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2022-08-22
Penalties and ownership
What sits behind the stars
$79,098
2023-11-08
Fine
Fine · fine $79,098
Fine
Ownership
Burnam, Soon
Corporate Officer · Individual
Dunyon, David
Operational/Managerial Control · Individual
Dunyon, David
Corporate Officer · Individual
Jorgensen, David
Corporate Director · Individual
Keetch, Chad
Corporate Officer · Individual
Sato, Ami
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Center At Centennial, The
Colorado Springs, CO
5-star overall rating with 4-star inspections with 1 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
#2
Springs Village Care Center
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
#3
Gardens, The
Colorado Springs, CO
5-star overall rating with 5-star inspections with 1 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
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