Inspection Reports for
Sunny Vista Living Center
2445 E CACHE LA POUDRE ST, COLORADO SPRINGS, CO, 80909-4812
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 6
Date: Jul 24, 2025
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to psychotropic medication use, respiratory support, mental health care, medication storage, infection control, and food safety at Sunny Vista Living Center.
Findings
The facility failed to ensure proper use and monitoring of psychotropic medications for several residents, timely provision of respiratory support equipment, appropriate mental health care including suicide risk management, proper medication storage and labeling, effective infection control practices, and sanitary food handling and storage.
Deficiencies (6)
F 0605: The facility failed to ensure psychotropic medications were used with proper documentation of behaviors, non-pharmacological interventions, and monitoring for five residents.
F 0684: The facility failed to obtain and provide a physician-ordered BiPAP machine for Resident #4 for nearly two months after admission.
F 0742: The facility failed to provide appropriate treatment and monitoring for Resident #12 with mental disorder and suicidal ideations, including lack of timely psychosocial evaluation and safety interventions.
F 0761: The facility failed to ensure medications were properly labeled with open dates, expired medications were discarded, and medication refrigerator temperatures were maintained within acceptable ranges.
F 0812: The facility failed to store, distribute, and serve food in a sanitary manner, including failure to clean and sanitize kitchen equipment and discard expired perishable foods.
F 0880: The facility failed to maintain infection control practices, including improper hand hygiene and disinfectant use by housekeeping staff and failure to perform hand hygiene during urinary catheter care for Resident #68.
Report Facts
Residents in sample: 52
Residents affected by psychotropic medication deficiency: 5
Residents affected by respiratory support deficiency: 1
Residents affected by mental health care deficiency: 1
Medication storage rooms with deficiencies: 2
Medication carts with deficiencies: 3
Temperature readings above acceptable range: 55
Temperature readings above acceptable range: 58
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding psychotropic medication administration and behavior monitoring |
| CNA #3 | Certified Nurse Aide | Interviewed regarding resident behaviors and documentation |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding resident behaviors and medication administration |
| SSD #1 | Social Services Director | Interviewed regarding behavior monitoring and respiratory equipment |
| NHA | Nursing Home Administrator | Interviewed regarding facility processes and resident behaviors |
| ADON | Assistant Director of Nursing | Interviewed regarding facility processes and resident care |
| MD | Medical Director | Interviewed regarding psychotropic medication and respiratory equipment |
| Regional Director of Clinical Operations | Interviewed regarding medication storage and infection control | |
| IP #2 | Infection Preventionist | Observed providing catheter care to Resident #68 |
| HK #1 | Housekeeper | Observed cleaning resident rooms with improper hand hygiene and disinfectant use |
Inspection Report
Routine
Deficiencies: 6
Date: Jul 24, 2025
Visit Reason
The inspection was conducted to evaluate compliance with regulations related to psychotropic medication use, respiratory support equipment, mental health care, medication storage, food safety, infection control, and other aspects of resident care at Sunny Vista Living Center.
Findings
The facility failed to ensure proper documentation and monitoring of psychotropic medication use for several residents, timely provision of respiratory support equipment, appropriate mental health care including monitoring for suicidal ideations, proper medication storage and labeling, sanitary food storage and preparation, and adherence to infection control protocols including hand hygiene and catheter care.
Deficiencies (6)
Failure to ensure psychotropic medications were used with proper documentation of behaviors and non-pharmacological interventions for residents #63, #46, #73, #112, and #50.
Failure to provide Resident #4 with a physician ordered BiPAP machine for almost two months after admission.
Failure to provide appropriate treatment and services to Resident #12 with mental disorder and history of trauma, including inadequate monitoring and response to suicidal ideations.
Failure to ensure medications were properly labeled with date opened, expired medications removed, and medication refrigerator temperatures maintained within acceptable range.
Failure to store, distribute, and serve food in a sanitary manner, including use of scored cutting boards, wet stacked pans, and expired perishable foods.
Failure to maintain infection control program including proper hand hygiene and disinfectant use by housekeeping staff and infection preventionist during catheter care for Resident #68.
Report Facts
Residents in sample: 52
Psychotropic medication sample residents affected: 5
Medication refrigerator temperature: 58
Depression screening scores: 10
BIMS scores: 0
BIMS scores: 7
BIMS scores: 11
BIMS scores: 15
Medication expiration dates: 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Interviewed regarding psychotropic medication administration and behavior monitoring |
| CNA #3 | Certified Nurse Aide | Interviewed regarding resident behaviors and documentation |
| CNA #4 | Certified Nurse Aide | Interviewed regarding resident behaviors and interventions |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding resident behaviors and medication administration |
| SSD #1 | Social Services Director | Interviewed regarding behavior monitoring and psychotropic medication management |
| MD | Medical Director | Interviewed regarding psychotropic medication management and resident care |
| RN #4 | Registered Nurse | Observed and interviewed regarding medication storage refrigerator temperature |
| LPN #8 | Licensed Practical Nurse | Observed medication cart and storage issues |
| Regional Director of Clinical Operations | Regional Director | Interviewed regarding medication storage and infection control |
| MTD | Maintenance Director | Interviewed regarding disinfectant use and medication refrigerator temperature |
| HK #1 | Housekeeper | Observed cleaning resident rooms with improper hand hygiene and disinfectant use |
| IP #2 | Infection Preventionist | Observed providing catheter care with improper hand hygiene |
| ADON | Assistant Director of Nursing | Interviewed regarding infection control and hand hygiene |
| Psychiatrist | Interviewed regarding Resident #12's mental health care and suicidal ideation | |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding monitoring for suicidal ideations |
| CNA #5 | Certified Nurse Aide | Interviewed regarding Resident #12's depression and suicidal ideations |
Inspection Report
Routine
Deficiencies: 2
Date: Sep 4, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing trauma-informed and culturally competent care, as well as appropriate treatment and services for residents with mental disorders or psychosocial adjustment difficulties.
Findings
The facility failed to ensure trauma survivors received culturally competent, trauma-informed care by not identifying PTSD triggers or developing individualized care plans for residents #3 and #4. Additionally, the facility failed to provide adequate psychosocial support and update care plans for resident #2, who had increasing depression and was not referred timely to psychological services.
Deficiencies (2)
F 0699: The facility failed to identify PTSD and triggers for residents #3 and #4 and did not develop person-centered care plans addressing their trauma-related needs.
F 0742: The facility failed to provide appropriate treatment and services to resident #2 with increasing depression, did not update the care plan to reflect worsening condition or recent suicidal ideation, and inaccurately documented antidepressant medication.
Report Facts
PHQ-9 severity score: 7
PHQ-9 severity score: 2
BIMS score: 13
BIMS score: 15
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Service Director | Interviewed regarding responsibilities for trauma assessments and care plan implementation | |
| Director of Nursing | Provided Trauma Informed Care policy and interviewed about care plan responsibilities |
Inspection Report
Deficiencies: 2
Date: Sep 4, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with providing trauma-informed and culturally competent care, appropriate treatment and services for residents with mental disorders or psychosocial adjustment difficulties, and to assess psychosocial support and care planning for residents with depression and PTSD.
Findings
The facility failed to ensure trauma-informed care for residents with PTSD by not identifying triggers or providing individualized care plans for two residents. Additionally, the facility failed to provide appropriate psychosocial support and update care plans for a resident with increasing depression, including inaccurate antidepressant medication documentation and delayed referral to psychological services.
Deficiencies (2)
Failed to provide trauma-informed and culturally competent care for residents with PTSD, including failure to identify triggers and develop individualized care plans.
Failed to provide appropriate treatment and services for a resident with mental disorder and psychosocial adjustment difficulty, including failure to update care plans and provide psychosocial support.
Report Facts
Residents affected: 2
Residents affected: 1
PHQ-9 score: 7
PHQ-9 score: 2
BIMS score: 13
BIMS score: 15
BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Provided Trauma Informed Care policy and interviewed regarding deficiencies | |
| Social Service Director | Interviewed regarding psychosocial support, care plans, and trauma assessments | |
| Nursing Home Administrator | Provided Psychosocial Evaluation policy |
Inspection Report
Routine
Deficiencies: 3
Date: Nov 30, 2023
Visit Reason
The inspection was a routine survey to assess compliance with food safety, kitchen sanitation, resident food storage, and emergency equipment maintenance standards.
Findings
The facility failed to maintain proper hand hygiene and glove use during meal service, failed to maintain dish machine sanitizing rinse temperatures, and did not keep the kitchen sanitary. Resident refrigerators were not properly monitored or maintained for safe food storage. Emergency crash carts were not properly maintained, contained expired items, lacked staff training, and storage rooms lacked required oxygen safety signage.
Deficiencies (3)
F 0812: The facility failed to ensure staff washed hands and changed gloves appropriately during meal service, maintain dish machine sanitizing rinse temperatures at or above 180°F, and keep the kitchen sanitary with proper cleaning schedules and debris removal.
F 0813: The facility failed to implement policy for safe use and storage of foods brought by visitors, including failure to monitor resident refrigerator temperatures and ensure food was labeled, dated, and stored safely.
F 0908: The facility failed to maintain emergency crash carts with complete, unexpired equipment and medications, ensure staff training on crash cart use and oxygen cylinder handling, complete daily equipment checks, and post required oxygen storage precautionary signage on storage rooms.
Report Facts
Dish machine rinse temperature: 180
Dish machine rinse temperature: 146
Dish machine rinse temperature: 148
Dish machine rinse temperature: 145
Dish machine rinse temperature: 174
Dish machine rinse temperature: 172
Dish machine rinse temperature: 177
Dish machine rinse temperature: 179
Dish machine rinse temperature: 161
Dish machine rinse temperature: 108
Dish machine rinse temperature: 140
Crash cart sterile water bottle expiration date: Apr 10, 2021
Crash cart normal saline expiration date: Jun 1, 2022
Ambu bag expiration date: Jan 30, 2022
Crash cart ambu bag expiration date: Apr 10, 2021
Crash cart daily checklist completion: 9
Crash cart daily checklist completion: 14
Crash cart daily checklist completion: 7
Crash cart daily checklist completion: 3
Crash cart daily checklist completion: 7
Crash cart daily checklist completion: 0
Crash cart daily checklist completion: 0
Resident refrigerator temperature: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA #1 | Dietary Aide | Named in multiple hand hygiene and glove use deficiencies during meal service |
| DA #2 | Dietary Aide | Named in hand hygiene and food handling deficiencies during meal service |
| DM | Dietary Manager | Interviewed regarding hand hygiene training, dish machine temperature monitoring, and kitchen sanitation |
| RD | Registered Dietitian | Interviewed regarding staff training and visitor food policy |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding crash cart #2 maintenance and oxygen cylinder knowledge |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding crash cart #1 maintenance and oxygen cylinder knowledge |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding crash cart #3 maintenance, training, and oxygen cylinder knowledge |
| RN #2 | Registered Nurse | Interviewed regarding crash cart #4 maintenance and oxygen cylinder knowledge |
| NHA | Nursing Home Administrator | Interviewed regarding facility policies, family council, and follow-up actions |
| DON | Director of Nursing | Interviewed regarding crash cart responsibilities, staff training, and emergency medication orders |
Inspection Report
Routine
Deficiencies: 5
Date: Nov 30, 2023
Visit Reason
The inspection was conducted to evaluate compliance with food safety, resident food storage, and emergency equipment maintenance standards at Sunny Vista Living Center.
Findings
The facility failed to maintain proper hand hygiene and glove use during meal service, failed to maintain dish machine sanitizing temperatures, and did not keep the kitchen sanitary. Resident personal refrigerators were not properly monitored or maintained, and the facility failed to implement its policy on food brought by visitors. Emergency crash carts were not properly maintained, contained expired items, lacked required signage, and staff were inadequately trained on their use.
Deficiencies (5)
Failure to ensure staff washed hands and changed single use gloves appropriately while plating and serving resident meals.
Failure to maintain high temperature dish washing machines at sanitizing rinse temperatures of at least 180 degrees Fahrenheit.
Failure to maintain the kitchen in a sanitary condition, including grease and debris buildup on floors and under equipment.
Failure to implement policy regarding use and storage of foods brought by visitors, including improper labeling, dating, and storage of resident personal refrigerator contents.
Failure to maintain emergency crash carts with complete, unexpired equipment and medications, failure to complete daily equipment checks, lack of staff training on crash cart use, and failure to post required oxygen storage signage.
Report Facts
Dish machine rinse temperature: 146
Dish machine rinse temperature: 148
Dish machine rinse temperature: 145
Dish machine rinse temperature: 174
Dish machine rinse temperature: 172
Dish machine rinse temperature: 177
Dish machine rinse temperature: 181
Dish machine rinse temperature: 185
Expired sterile water bottles: 2
Expired normal saline bottles: 2
Expired ambu bag: 1
Expired ambu bag: 1
Crash cart daily checklist completion: 9
Crash cart daily checklist completion: 14
Resident refrigerator temperature readings above 41°F: 20
Resident refrigerator temperature missing recordings: 19
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA #1 | Dietary Aide | Named in multiple hand hygiene and glove use deficiencies during meal service observations. |
| DA #2 | Dietary Aide | Named in hand hygiene and glove use deficiencies during meal service observations. |
| DM | Dietary Manager | Provided interviews regarding staff training and observations of deficiencies; responsible for food service oversight. |
| RD | Registered Dietitian | Provided interviews regarding staff training and visitor food policy. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding crash cart #2; unable to verify medication requirements or oxygen cylinder replacement. |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding crash cart #1; unaware of oxygen cylinder replacement level. |
| LPN #3 | Licensed Practical Nurse | Interviewed regarding crash cart #3; unaware of crash cart location, training, and equipment requirements. |
| RN #2 | Registered Nurse | Interviewed regarding crash cart #4; unaware of oxygen cylinder use and equipment requirements. |
| NHA | Nursing Home Administrator | Provided interviews regarding policies, family council discussions, and follow-up actions. |
| DON | Director of Nursing | Provided interviews regarding crash cart responsibilities, staff training, and follow-up plans. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 2, 2023
Visit Reason
The inspection was conducted following a complaint regarding a medication error where a licensed practical nurse administered medication not ordered for a resident.
Complaint Details
The complaint investigation found that the nurse administered Ativan without an order, using her personal medication. The incident was substantiated, the nurse was suspended and reported to the Board of Nursing, and the facility implemented corrective actions including staff education and competency checks.
Findings
The facility failed to ensure residents were free from significant medication errors, specifically a nurse administered Ativan without a physician's order to Resident #1. The nurse was removed from the schedule, reported to the Board of Nursing, and the facility provided staff training on medication administration.
Deficiencies (1)
F 0760: The facility failed to ensure Resident #1 was not administered Ativan by a licensed practical nurse without a physician order. The nurse used her personal medication supply to administer the drug, violating facility policy and nursing standards.
Report Facts
Residents affected: 1
Date survey completed: Feb 2, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Administered Ativan without physician order; suspended and reported to Board of Nursing |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration policies |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication administration policies |
| RN #1 | Registered Nurse | Interviewed regarding medication administration education and standards |
| DON | Director of Nursing | Interviewed regarding the incident and corrective actions |
| NHA | Nursing Home Administrator | Interviewed regarding the incident and facility policies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 2, 2023
Visit Reason
The inspection was conducted following a complaint regarding a medication error where a licensed practical nurse administered Ativan to a resident without a physician's order.
Complaint Details
The complaint investigation revealed that LPN #3 administered crushed Ativan from her personal supply to Resident #1 without a physician's order. The resident was experiencing extreme discomfort and panic. The nurse attempted to obtain an order but administered the medication before it arrived. The nurse was suspended and reported to the Board of Nursing. The resident passed away shortly after administration.
Findings
The facility failed to ensure residents were free from significant medication errors, specifically that Resident #1 was administered Ativan by an LPN without an order. The nurse used her personal medication supply, and the resident passed away shortly after. The facility conducted an investigation, removed the nurse from the schedule, reported her to the Board of Nursing, and provided staff education on medication administration.
Deficiencies (1)
Failure to ensure Resident #1 was not administered Ativan by LPN #3 without a physician order.
Report Facts
Residents affected: 1
Date survey completed: Feb 2, 2023
Date of resident death: Sep 13, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Administered Ativan without physician order; agency nurse; suspended and reported to Board of Nursing |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication administration policies |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding medication administration policies |
| RN #1 | Registered Nurse | Interviewed regarding medication administration education and standards |
| DON | Director of Nursing | Interviewed regarding nurse's actions and facility response |
| NHA | Nursing Home Administrator | Interviewed regarding nurse's actions and facility response |
Inspection Report
Routine
Census: 106
Deficiencies: 5
Date: Aug 11, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident care, activities, medication administration, infection control, and safety in a nursing home facility.
Findings
The facility failed to provide adequate nail care for residents unable to perform ADLs, failed to provide meaningful activities for a bedbound resident, failed to administer tube feedings per physician orders, failed to secure medication carts, and failed to implement an effective COVID-19 infection prevention and control program including proper PPE use, fit testing, signage, and isolation practices.
Deficiencies (5)
F 0677: The facility failed to ensure residents unable to perform ADLs received necessary nail care, resulting in untrimmed nails with debris for two residents.
F 0679: The facility failed to provide a meaningful activity program tailored to the individual needs of a bedbound resident, resulting in lack of scheduled one-on-one visits.
F 0693: The facility failed to provide tube feeding per physician orders on two occasions for one resident, including a documented medication error.
F 0761: The facility failed to ensure medication carts were locked when unattended, observed unlocked medication cart in hallway.
F 0880: The facility failed to implement an effective COVID-19 infection control program, including improper PPE use, lack of fit testing for N95 masks, inadequate signage for isolation precautions, and failure to keep COVID-19 positive resident room doors closed.
Report Facts
COVID-19 positive residents: 16
N95 masks available: 5489
Medication administration error: 1
Residents census: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in relation to nail care responsibility and medication administration observations |
| Director of Nursing | Director of Nursing (DON) | Provided statements regarding nail care, tube feeding, medication cart security, and infection control policies |
| Administrator | Administrator (ADM) | Provided statements regarding facility expectations for nail care, tube feeding, medication cart security, and infection control |
| Infection Preventionist | Infection Preventionist (IP) | Provided statements regarding COVID-19 PPE use, fit testing, and infection control practices |
| CNA #1 | Certified Nursing Assistant | Observed and interviewed regarding PPE use and nail care notifications |
| CNA #5 | Certified Nursing Assistant | Observed and interviewed regarding PPE use and nail care notifications |
Inspection Report
Routine
Census: 106
Deficiencies: 5
Date: Aug 11, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, activities, medication administration, infection control, and safety in the nursing home.
Findings
The facility was found deficient in multiple areas including failure to provide adequate nail care for residents unable to perform ADLs, failure to provide meaningful activity programs for bedbound residents, failure to administer tube feedings per physician orders, failure to secure medication carts, and failure to implement effective COVID-19 infection prevention and control measures including improper PPE use, lack of fit testing for N95 masks, inadequate signage for isolation precautions, and failure to keep COVID-19 positive resident room doors closed.
Deficiencies (5)
Failed to ensure residents unable to carry out ADLs, specifically nail care, received necessary services to maintain clean, trimmed nails for two residents.
Failed to provide a meaningful program of activities for one bedbound resident, not meeting individual activity needs and interests.
Failed to provide enteral nutrition per physician's order for one resident requiring tube feeding on two occasions.
Failed to ensure medication carts were locked when unattended for one medication cart observed.
Failed to implement an effective infection prevention and control program to prevent spread of COVID-19, including improper PPE use, lack of N95 fit testing, inadequate signage for isolation precautions, and failure to keep COVID-19 positive resident room doors closed.
Report Facts
Residents affected: 2
Residents affected: 1
Residents affected: 1
Medication carts observed: 3
Medication carts unlocked: 1
Residents affected: 16
N95 masks available: 5489
Residents census: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Named in relation to nail care responsibility and medication administration observations |
| Certified Nursing Assistant #1 | CNA | Named in relation to nail care and infection control PPE observations |
| Certified Nursing Assistant #5 | CNA | Named in relation to nail care and infection control PPE observations |
| Director of Nursing | DON | Named in relation to multiple findings including nail care, tube feeding, medication cart security, and infection control |
| Administrator | ADM | Named in relation to multiple findings including nail care, tube feeding, medication cart security, and infection control |
| Infection Preventionist | IP | Named in relation to infection control program and PPE use |
| Licensed Practical Nurse #2 | LPN | Named in relation to infection control PPE use and fit testing |
| Registered Nurse #1 | RN | Named in relation to activity program and infection control observations |
| Life Enrichment Director | LED | Named in relation to activity program deficiency |
| Environmental Services Director | ESD | Named in relation to infection control PPE use observations |
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