Deficiencies (last 4 years)
Deficiencies (over 4 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to prevent elopement of a resident during an offsite medical appointment.
Complaint Details
The complaint investigation found that Resident #1 eloped during a neurologist appointment on 9/9/25 due to lack of supervision. The resident was missing for several hours and was found 3.4 miles away from the clinic. The facility had not identified the resident as an elopement risk prior to the incident despite documented wandering behaviors. The facility corrected the deficient practice prior to the onsite investigation.
Findings
The facility failed to ensure Resident #1, who had cognitive impairments and a history of wandering, was properly supervised during a medical appointment offsite, resulting in the resident eloping and being found 3.4 miles away several hours later. The facility implemented corrective actions including updated elopement risk assessments, staff education, and revised procedures for escorting residents to appointments.
Deficiencies (1)
Failure to ensure residents received adequate supervision and were kept free from elopement for one of three residents at risk for elopement.
Report Facts
Residents at risk for elopement: 3
Distance resident eloped: 3.4
Time missing: 4
Correction date: Sep 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Found Resident #1 after elopement and involved in corrective actions |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Provided plan of correction and education related to elopement incident |
| CNA #1 | Certified Nurse Aide | Monitored wandering behaviors of Resident #1 |
| Transportation coordinator #1 | Transportation Coordinator | Involved in arranging transportation and escorts for residents |
| Registered Nurse #2 | Registered Nurse | Provided information on elopement risk evaluations and resident wandering |
| Social Services Assistant | Social Services Assistant (SSA) | Communicated with resident's representative about appointment and escort needs |
| Case Manager | Case Manager | Managed transportation documentation and appointment scheduling |
| Transportation coordinator #2 | Transportation Coordinator | Managed escort scheduling and transportation arrangements |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 9, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide adequate supervision to prevent elopement of a resident during an off-site medical appointment.
Complaint Details
The complaint investigation found that Resident #1 eloped during a scheduled medical appointment on 9/9/25 due to lack of supervision. The resident was missing for several hours and was found 3.4 miles away from the appointment location. The facility was cited for past noncompliance and implemented a plan of correction including audits, staff education, updated policies, and escort procedures.
Findings
The facility failed to ensure Resident #1, who had cognitive impairments and a history of wandering, was properly supervised during a medical appointment, resulting in the resident eloping and being found 3.4 miles away several hours later. The facility implemented corrective actions including updated elopement risk assessments, staff education, and revised procedures for escorting residents to appointments.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provided adequate supervision to prevent accidents, resulting in immediate jeopardy to resident health or safety.
Report Facts
Residents at risk for elopement: 3
Distance resident eloped: 3.4
Time resident missing: 4
Correction date: Sep 12, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Found Resident #1 after elopement and involved in corrective actions. |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Provided plan of correction and education to staff regarding elopement incident. |
| Transportation Coordinator #1 | Transportation Coordinator | Involved in appointment and escort coordination; interviewed about incident. |
| Transportation Coordinator #2 | Transportation Coordinator | Managed escort scheduling and interviewed regarding incident. |
| Registered Nurse #2 | Registered Nurse (RN) | Interviewed about elopement risk assessments and resident wandering behaviors. |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Monitored resident wandering behaviors and reported on elopement incident. |
| Social Services Assistant | Social Services Assistant (SSA) | Communicated with resident's representative and transportation staff about appointment. |
| Case Manager | Case Manager | Managed transportation documentation and appointment scheduling. |
Inspection Report
Routine
Deficiencies: 2
Date: Apr 16, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident care and treatment, specifically focusing on communication assistance for Resident #15 and proper application of compression stockings for Resident #55.
Findings
The facility failed to provide Resident #15 with appropriate communication tools to effectively communicate needs, and failed to assist Resident #55 with applying compression stockings as ordered, despite physician orders and care plan requirements. Both deficiencies were identified as causing minimal harm or potential for actual harm affecting a few residents.
Deficiencies (2)
Failed to provide Resident #15, who had speech difficulties due to stroke, with an appropriate communication tool to ensure effective communication of needs.
Failed to assist Resident #55 with applying compression stockings to treat bilateral lower leg edema according to physician orders and care plan.
Report Facts
Sample residents reviewed: 28
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #2 | Certified Nurse Aide | Mentioned in communication deficiency observation and interview with Resident #15 |
| CNA #1 | Certified Nurse Aide | Mentioned in communication and compression stocking deficiencies |
| RN #1 | Registered Nurse | Mentioned in communication deficiency regarding communication board availability |
| UCC #1 | Unit Care Coordinator | Mentioned in communication and compression stocking deficiencies |
| LPN #1 | Licensed Practical Nurse | Mentioned in compression stocking deficiency |
| DON | Director of Nursing | Provided education and interviewed regarding both deficiencies |
| ST | Speech Therapist | Interviewed regarding Resident #15 communication assessment |
| SSA #1 | Social Services Assistant | Interviewed regarding awareness of communication board for Resident #15 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 16, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide appropriate communication tools for Resident #15 and to assist Resident #55 with applying compression stockings as ordered.
Complaint Details
The complaint investigation substantiated that Resident #15 was not provided with appropriate communication tools and Resident #55 was not assisted with compression stockings as ordered, resulting in minimal harm or potential for actual harm.
Findings
The facility failed to provide Resident #15 with an appropriate communication tool to effectively communicate needs and failed to assist Resident #55 with applying compression stockings to treat bilateral lower leg edema, despite physician orders and care plans.
Deficiencies (2)
F 0676: The facility failed to provide Resident #15, who had speech difficulties due to a stroke, with an appropriate communication tool to ensure effective communication of needs to staff.
F 0684: The facility failed to ensure Resident #55 was assisted with applying compression stockings to treat bilateral lower leg edema according to physician orders and professional standards.
Report Facts
Sample residents reviewed: 28
Residents affected: 1
Residents affected: 1
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure adequate supervision and timely nursing assessment after a resident's fall during occupational therapy treatment.
Complaint Details
The complaint investigation found that Resident #1 fell during occupational therapy on 9/10/23. The occupational therapist did not notify nursing staff or request an assessment after the fall. The resident sustained injuries including a distal clavicle fracture and rotator cuff tear. The facility policy requires a registered nurse to assess residents after falls, which was not followed. The occupational therapist was new and unaware of the post-fall policy but received training after the incident.
Findings
The facility failed to provide adequate supervision to Resident #1 during occupational therapy, resulting in a fall with injury. Additionally, the occupational therapist did not notify nursing staff for a timely post-fall assessment, violating facility policy. Subsequent assessments revealed a distal clavicle fracture and rotator cuff injury.
Deficiencies (2)
Failure to ensure adequate supervision during occupational therapy to prevent a fall.
Failure to perform timely and appropriate post-fall nursing assessment by a registered nurse.
Report Facts
Date of fall: Sep 10, 2023
Date of survey completion: Nov 7, 2023
MRI measurement: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Called to assess Resident #1 after fall and reported OT did not notify nursing |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed and provided education to OT on post-fall policy |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding facility policy on post-fall assessments and OT training |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 7, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding inadequate supervision and failure to provide timely post-fall nursing assessment for Resident #1 following a fall during occupational therapy treatment.
Complaint Details
The complaint investigation found that Resident #1 fell during occupational therapy on 9/10/23. The occupational therapist did not inform nursing staff immediately, delaying assessment. The resident sustained injuries including a distal clavicle fracture and rotator cuff tear. The facility policy requires registered nurse assessment after falls, which was not followed. The occupational therapist received additional training post-incident.
Findings
The facility failed to ensure adequate supervision of Resident #1 during occupational therapy, resulting in a fall with injury. Additionally, the occupational therapist did not notify nursing staff promptly, delaying the required post-fall nursing assessment and evaluation.
Deficiencies (1)
F 0689: The facility failed to ensure Resident #1 received adequate supervision during occupational therapy to prevent a fall and failed to provide timely post-fall nursing assessment by a registered nurse.
Report Facts
Date of fall: Sep 10, 2023
Date of survey completion: Nov 7, 2023
MRI measurement: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding post-fall nursing assessment and notification failures. |
| Director of Rehabilitation | Director of Rehabilitation | Interviewed about occupational therapist's failure to notify nursing staff and post-fall policy training. |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed about facility policy on post-fall assessments and occupational therapist training. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 19, 2023
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to ensure a resident with a new mental health diagnosis was referred for a level two pre-admission screening and resident review (PASRR), and to assess compliance with policies regarding influenza and pneumococcal vaccinations.
Complaint Details
The complaint investigation focused on Resident #49's mental health PASRR screening and Resident #7's influenza vaccination process. The complaint was substantiated with findings of failure to refer for level two PASRR and failure to provide proper vaccine education and assessment.
Findings
The facility failed to refer Resident #49 for a required level two PASRR screening after new mental health diagnoses and medication changes. Additionally, the facility failed to assess Resident #7 for medical contraindications and provide education prior to influenza vaccine administration. Both deficiencies were determined to cause minimal harm or potential for actual harm affecting a few residents.
Deficiencies (2)
Failure to ensure a resident with a new mental health diagnosis was referred for a level two PASRR screening and resident review.
Failure to assess a resident for medical contraindications and provide education on the influenza vaccine prior to administration.
Report Facts
Medication dosage: 100
Medication dosage: 10
Residents reviewed for immunizations: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Provided information about PASRR screening process and submission delays for Resident #49 | |
| Medical Director | Discussed Resident #49's diagnosis and treatment plan | |
| Director of Nursing | Discussed responsibilities related to PASRR screening and vaccine consent | |
| Infection Preventionist / RN | Discussed Resident #7's influenza vaccination and consent issues | |
| Executive Director | Discussed PASRR screening procedures and future improvements |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 19, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to refer a resident with a new mental health diagnosis for a level two pre-admission screening and resident review (PASRR), and failure to properly assess and educate a resident prior to influenza vaccination.
Complaint Details
The complaint investigation focused on Resident #49's lack of timely referral for a level two PASRR after new mental health diagnoses and medication changes, and Resident #7's influenza vaccination without proper assessment, education, or consent documentation. The findings substantiated these issues.
Findings
The facility failed to ensure Resident #49 was referred timely for a level two PASRR after new mental health diagnoses and medication changes. The facility also failed to assess Resident #7 for medical contraindications and provide education before administering the influenza vaccine. Both deficiencies were cited with minimal harm and affected few residents.
Deficiencies (2)
F 0644: The facility failed to refer Resident #49 for a level two PASRR screening after new mental health diagnoses and initiation of psychotropic medications, despite policy requirements.
F 0883: The facility failed to assess Resident #7 for medical contraindications and provide education on the influenza vaccine prior to administration, and did not obtain a new consent form after the resident changed their mind.
Report Facts
Residents reviewed for immunizations: 5
Residents affected: 1
Residents affected: 1
Medication dosage: 100
Medication dosage: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Social Services Director (SSD) | Interviewed regarding PASRR screening process and delays for Resident #49. |
| Medical Director | Medical Director (MD) | Interviewed about Resident #49's diagnosis and treatment. |
| Director of Nursing | Director of Nursing (DON) | Interviewed about PASRR responsibilities and influenza vaccine consent. |
| Infection Preventionist | Infection Preventionist (IP)/RN | Interviewed about influenza vaccine administration to Resident #7. |
| Executive Director | Executive Director (ED) | Interviewed about PASRR screening procedures and future improvements. |
Inspection Report
Routine
Deficiencies: 8
Date: Oct 14, 2021
Visit Reason
The inspection was a routine survey of Life Care Center of Colorado Springs to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and other facility operations.
Findings
The facility was found deficient in multiple areas including failure to provide timely showers and repositioning for residents, inadequate documentation and treatment of skin abrasions, failure to obtain physician orders for medication application, lack of range of motion services, improper oxygen therapy administration, medication errors including failure to prime insulin needles, and ineffective infection prevention and control practices such as inadequate hand hygiene and source control.
Deficiencies (8)
Failure to provide showers as scheduled for residents #13, #272, and #61.
Failure to reposition residents #17, #44, and #21 in their wheelchairs timely.
Failure to accurately document skin assessments and provide care and treatments for abrasion on resident #21's right knee.
Failure to have a physician order for Lidocaine lotion applied to Resident #19's hand.
Failure to provide range of motion services to Resident #17's lower extremities and failure to provide a restorative program regularly to Resident #29.
Failure to administer oxygen therapy as ordered and failure to label/date oxygen tubing for six residents (#70, #25, #52, #43, #17, and #26).
Medication error rate greater than 5%, including failure to administer heart failure medication and failure to prime insulin needle prior to administration for Resident #16.
Failure to ensure effective infection prevention and control program including lack of hand sanitation offered prior to meals, inadequate source control for staff and visitors, and improper hand hygiene by housekeeping staff.
Report Facts
Medication error rate: 8
Missed showers: 2
Shower frequency: 7
Missed restorative therapy sessions: 7
Oxygen flow rate discrepancy: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed medication administration including insulin injection without priming needle. |
| LPN #2 | Licensed Practical Nurse | Unit manager who provided education on insulin administration and reported medication errors. |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication errors, infection control, and care plans. |
| CNA #4 | Certified Nurse Aide | Involved in resident care observations and interviews regarding repositioning and lotion application. |
| LPN #4 | Licensed Practical Nurse, Restorative Program Manager | Interviewed about restorative program and resident care. |
| RCNA #1 | Restorative Certified Nurse Aide | Interviewed about restorative program delivery and staffing. |
| UM | Unit Manager | Interviewed regarding oxygen therapy and shower documentation. |
| SDC | Staff Development Coordinator / Infection Preventionist | Interviewed about infection control training and COVID-19 protocols. |
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Oct 14, 2021
Visit Reason
The inspection was an annual survey to assess compliance with regulatory requirements for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to provide timely assistance with activities of daily living, inadequate skin care and treatment, failure to provide range of motion and restorative services, improper respiratory care including oxygen therapy management, medication administration errors, and ineffective infection prevention and control practices.
Deficiencies (7)
F 0677: The facility failed to provide timely assistance with activities of daily living including showering and repositioning for multiple residents.
F 0684: The facility failed to accurately document skin assessments and provide treatment for abrasions on Resident #21's right knee and failed to have a physician order for Lidocaine lotion applied to Resident #19's hand.
F 0688: The facility failed to provide range of motion services to Resident #17 and failed to provide a restorative program regularly to Resident #29.
F 0695: The facility failed to provide safe and appropriate respiratory care by not administering oxygen as ordered and failing to label and date oxygen tubing for multiple residents.
F 0759: The facility failed to ensure medication error rates were below 5%, specifically failing to administer heart failure medication and failing to prime insulin needles prior to administration for Resident #16.
F 0760: The facility failed to keep Resident #16 free from significant medication errors by not priming insulin needles prior to injection.
F 0880: The facility failed to implement an effective infection prevention and control program including failure to offer hand sanitation prior to meals, inadequate source control for staff and visitors, and improper hand hygiene by housekeeping staff.
Report Facts
Medication error rate: 8
Missed restorative therapy sessions: 7
Residents reviewed: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed medication administration errors including failure to prime insulin needle. |
| LPN #2 | Licensed Practical Nurse | Unit manager who provided education on insulin administration and reported medication errors. |
| LPN #4 | Licensed Practical Nurse, Restorative Program Manager | Managed restorative program and acknowledged staffing issues affecting therapy delivery. |
| RCNA #1 | Restorative Certified Nurse Aide | Reported being pulled to floor duties, limiting restorative therapy provision. |
| DON | Director of Nursing | Provided interviews regarding multiple deficiencies including infection control and medication administration. |
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