10 health deficiencies
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
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
110 W Van Buren St, Colorado Springs, CO
(719) 475-8686
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Beds
91
Certified beds
Average residents
86
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Stellar Senior Living
Operator or chain grouping
Approved since
1989-03-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 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
0.68
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.68
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
1.79
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.15
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.36
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.44
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.69
CMS adjusted RN staffing hours
Adjusted total hours
3.20
CMS adjusted total nurse staffing hours
Case-mix index
1.35
Higher values indicate more complex resident acuity
RN turnover
41%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Program rank
12,637
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
11.32
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
0.76
Baseline 80.90% · Performance 73.81% · Measure score 0.76 · Achievement 0 · Improvement 0.76
Adjusted total nurse staffing
1.50
Baseline 3.35 hours · Performance 3.50 hours · Measure score 1.50 · Achievement 1.50 · Improvement 0.14
SNF QRP
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 9.47% |
10.72%
1.2 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 4.26% · Lower 95% interval 5.99% |
| Discharge to community | 49.94% |
50.57%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 43 · Observed rate 41.86% · Lower 95% interval 35.91% |
| Medicare spending per beneficiary | 1.38 |
1.02
0.4 pts worse
|
|
| Drug regimen review with follow-up | 91.67% |
95.27%
3.6 pts worse
|
Numerator 33 · Denominator 36 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 36 |
| Discharge self-care score | 46.15% |
53.69%
7.5 pts worse
|
Numerator 12 · Denominator 26 |
| Discharge mobility score | 38.46% |
50.94%
12.5 pts worse
|
Numerator 10 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 36 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 17 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 3.6% |
8.2%
4.6 pts worse
|
Numerator 4 · Denominator 111 |
| Staff flu vaccination coverage | 97.57% |
42%
55.6 pts better
|
Numerator 201 · Denominator 206 |
| Discharge function score | 38.46% |
56.45%
18 pts worse
|
Numerator 10 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 18 · Too few residents or stays to report publicly. |
Quality measures
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.7 |
1.3
0.6 pts better
|
1.9
1.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.7 · Observed 1.0 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
1.7
0.9 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.0 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 90.3% |
93.5%
3.2 pts worse
|
93.4%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 81.8% · Q2 83.3% · Q3 95.1% · Q4 100.0% · 4Q avg 90.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.6% |
94.7%
2.9 pts better
|
95.5%
2.1 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.4%
1.7 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 1.2% · Q4 4.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.6% |
7.4%
2.8 pts better
|
11.4%
6.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.2% · Q2 1.3% · Q3 8.5% · Q4 5.6% · 4Q avg 4.6% |
| Percentage of long-stay residents who lose too much weight | 5.1% |
5.0%
0.1 pts worse
|
5.4%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.6% · Q3 4.0% · Q4 6.0% · 4Q avg 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.4% |
11.2%
0.8 pts better
|
19.6%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.9% · Q2 11.0% · Q3 9.2% · Q4 10.4% · 4Q avg 10.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 20.6% |
20.6%
About the same
|
16.7%
3.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 17.3% · Q2 20.4% · Q3 23.7% · Q4 20.8% · 4Q avg 20.6% · 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 | 11.5% |
15.2%
3.7 pts better
|
16.3%
4.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.4% · Q2 5.3% · Q3 10.6% · Q4 15.2% · 4Q avg 11.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 12.9% |
14.6%
1.7 pts better
|
14.9%
2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.3% · Q2 12.5% · Q3 11.6% · Q4 7.9% · 4Q avg 12.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.8%
0.1 pts better
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 1.1% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.0% |
1.5%
0.5 pts better
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.3% · Q3 2.5% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.8% |
22.4%
2.4 pts worse
|
19.8%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.1% · Q2 21.0% · Q3 22.9% · Q4 21.7% · 4Q avg 24.8% |
| Percentage of long-stay residents with pressure ulcers | 5.6% |
3.7%
1.9 pts worse
|
5.1%
0.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.3% · Q3 7.6% · Q4 4.4% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 76.6% |
76.4%
0.2 pts better
|
81.7%
5.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 76.4% · Q2 71.2% · Q3 76.3% · Q4 83.7% · 4Q avg 76.6% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 5.6% |
1.5%
4.1 pts worse
|
1.6%
4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 4.5% · Q3 9.1% · Q4 4.2% · 4Q avg 5.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 65.5% |
75.6%
10.1 pts worse
|
79.7%
14.2 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 65.5% |
Survey summary
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Top issue: Quality of Life and Care (11 deficiencies)
6 fire-safety deficiencies
Top issue: Services (2 deficiencies)
Top issue: Resident Rights (4 deficiencies)
8 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (3 deficiencies)
Fire safety
Fire Safety
Establish policies and procedures including evacuation.
Corrected 2025-06-14
Fire Safety
Conduct testing and exercise requirements.
Corrected 2025-06-14
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-07-02
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-07-02
Fire Safety
Provide properly protected cooking facilities.
Corrected 2025-07-02
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-07-02
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-07-02
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2025-07-02
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 2024-01-11
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-27
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-01-11
Fire Safety
Install properly constructed and protected linen or trash chutes.
Corrected 2024-01-11
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-11
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-01-11
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2020-04-05
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2020-04-05
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2020-04-05
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2020-04-05
Fire Safety
Ensure proper storage of liquid oxygen.
Corrected 2020-04-05
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2020-04-05
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2020-04-05
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2020-04-05
Inspection history
Health
Ensure the transfer/discharge meets the resident's needs/preferences and that the resident is prepared for a safe transfer/discharge.
Corrected 2026-02-13
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2025-06-14
Health
Provide and implement an infection prevention and control program.
Corrected 2025-06-14
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2025-06-14
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2025-06-14
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-06-14
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2025-06-14
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-06-14
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-06-14
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 2025-06-14
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-03-19
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-03-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-03-19
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2025-03-19
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-19
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-05-22
Health
Respond appropriately to all alleged violations.
Corrected 2024-05-22
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2024-02-21
Health
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Corrected 2024-02-21
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-19
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-10-19
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-10-19
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-19
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-10-19
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-19
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2023-10-19
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 2023-10-19
Health
Provide activities to meet all resident's needs.
Corrected 2023-10-19
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2023-10-19
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-19
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 2023-10-19
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-10-19
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-10-19
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2023-10-19
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-19
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 2023-04-13
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2023-04-13
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-04-17
Penalties and ownership
Fine · fine $26,845
Fine
Payment Denial · denial start 2023-10-13 · 6 days
6 day denial
5% Or Greater Direct Ownership Interest · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
Corporate Officer · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Individual
Operational/Managerial Control · Individual
Corporate Director · Individual
Operational/Managerial Control · Individual
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
Operational/Managerial Control · Organization
5% Or Greater Indirect Ownership Interest · Organization
Operational/Managerial Control · Organization
Nearby options
Colorado Springs, CO
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
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
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
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