Inspection Reports for
The Healthcare Resort of Colorado Springs
2818 GRAND VISTA CIR, COLORADO SPRINGS, CO, 80904-
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
7.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
48% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Deficiencies: 9
Date: Jun 26, 2025
Visit Reason
Routine state inspection of Healthcare Resort of Colorado Springs to assess compliance with regulatory standards including resident rights, care, medication administration, food safety, hospice services, and laboratory services.
Findings
The facility failed to consistently honor resident dining choices, provide adequate assistance with activities of daily living, ensure timely and accurate oxygen therapy, maintain medication error rates below 5%, properly store medications and vaccines, provide timely laboratory services, maintain sanitary food preparation conditions, and coordinate hospice care effectively.
Deficiencies (9)
F 0561: The facility failed to honor resident choices by not ensuring the dining room was open for dinner and on weekends, limiting residents' ability to dine socially.
F 0677: The facility failed to provide necessary bathing assistance to residents #144 and #146 according to their care plans, including lack of shower assistance and supervision.
F 0679: The facility failed to provide group activities on weekends for Resident #76, limiting socialization opportunities.
F 0695: The facility failed to provide oxygen therapy to Residents #60 and #74 according to physician orders, administering higher oxygen flow rates than ordered.
F 0759: The facility had a medication error rate of 7.14%, including failure to correctly dose meloxicam and improper dispensing of Voltaren gel.
F 0761: The facility failed to properly store medications and vaccines, including storing vaccines in a dormitory-style refrigerator, keeping expired vaccines, unlabeled Tubersol vials, loose pills in medication carts, and medications not stored by route or in original packaging.
F 0770: The facility failed to ensure timely laboratory services for Resident #12, including delayed follow-up on an unlabeled urine sample and delayed antibiotic treatment for UTI symptoms.
F 0812: The facility failed to thaw meat safely by not using running water and failed to prevent dietary staff from wearing jewelry during food preparation and service.
F 0849: The facility failed to coordinate hospice services effectively for Residents #24 and #60, including lack of accessible hospice documentation and failure to update care plans timely for hospice care.
Report Facts
Medication error rate: 7.14
Oxygen flow rate: 5
Oxygen flow rate: 6
Medication dose: 7.5
Medication dose: 2
Expired vaccine count: 42
Urine sample collection dates: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Failed to correctly dispense meloxicam dose |
| CNA-Med #1 | Certified Nurse Aide with Medication Authority | Dispensed Voltaren gel incorrectly |
| CK #1 | Cook | Wore jewelry during food preparation and meal service |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including oxygen therapy, medication errors, vaccine storage, and hospice care coordination |
| RDC | Regional Dietary Consultant | Provided education on thawing practices and jewelry policy |
| DM | Dietary Manager | Observed thawing practices and jewelry during meal service |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #12's lab delays and antibiotic orders |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding oxygen therapy and medication cart storage |
| MDSC #1 | Minimum Data Set Coordinator | Interviewed regarding hospice care plan updates |
| MDSC #2 | Minimum Data Set Coordinator | Interviewed regarding hospice care plan updates |
| ADON | Assistant Director of Nursing | Interviewed regarding hospice communication and care plan updates |
| RCR | Regional Clinical Resource | Interviewed regarding hospice care coordination and lab follow-up |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #60 hospice care |
| CNA #2 | Certified Nurse Aide | Interviewed regarding hospice care for Resident #24 |
| LPN #5 | Licensed Practical Nurse | Interviewed regarding hospice care for Resident #24 |
| CNA #3 | Certified Nurse Aide | Interviewed regarding hospice care for Resident #24 |
| ED | Executive Director of Hospice Provider | Interviewed regarding hospice visits and communication |
Inspection Report
Enforcement
Deficiencies: 2
Date: Nov 8, 2023
Visit Reason
The inspection was conducted due to allegations and findings of staff-to-resident verbal and mental abuse by a certified nurse aide (CNA #1) toward multiple residents, resulting in immediate jeopardy to resident health and safety.
Complaint Details
The investigation was triggered by multiple complaints and reports from residents, visitors, and staff about verbal and mental abuse by CNA #1. Despite repeated reports starting as early as February 2023, the facility failed to recognize these as abuse, delayed investigations, and did not protect residents from further harm. The abuse was substantiated and resulted in immediate jeopardy.
Findings
The facility failed to protect residents from verbal and mental abuse by CNA #1, failed to recognize and investigate repeated complaints as abuse, and failed to implement effective corrective actions. The abuse caused actual serious harm to several residents and created immediate jeopardy. The facility's abuse investigations were incomplete and delayed, and corrective actions were insufficient.
Deficiencies (2)
F 0600: The facility failed to protect six residents from mental and verbal abuse by CNA #1, causing anxiety, fear, humiliation, and night terrors. Complaints were not properly reported or investigated, leading to immediate jeopardy and actual harm.
F 0610: The facility failed to respond appropriately to alleged violations by not thoroughly investigating incidents of potential abuse involving five residents and not reporting to authorities as required.
Report Facts
Residents in sample: 42
Residents affected by abuse: 6
Residents with substantiated abuse: 5
Date of CNA termination: Oct 27, 2023
Date of survey completion: Nov 8, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA #1) | Identified as perpetrator of verbal and mental abuse toward residents | |
| Nursing Home Administrator (NHA) | Responsible for abuse investigations and facility response; interviewed multiple times | |
| Director of Nursing (DON) | Provided counseling/disciplinary notices to CNA #1 and involved in grievance follow-up | |
| Social Service Director (SSD) | Conducted interviews and investigations related to abuse allegations | |
| Human Resources Director (HRD) | Provided staffing records and disciplinary notices for CNA #1 | |
| Director of Rehabilitation Services (DOR) | Participated in abuse education and competency training | |
| Clinical Nurse Resource and Social Service Resource | Conducted education and audits to prevent abuse |
Inspection Report
Complaint Investigation
Deficiencies: 9
Date: Nov 8, 2023
Visit Reason
The inspection was conducted due to complaints and allegations of verbal and mental abuse by a certified nurse aide (CNA #1) towards multiple residents, as well as concerns about the facility's failure to protect residents from abuse and to properly report and investigate such incidents.
Complaint Details
The complaint investigation focused on allegations of verbal and mental abuse by CNA #1 towards multiple residents (#4, #8, #15, #87, #253). Residents and visitors reported rude, aggressive, and intimidating behavior by CNA #1, including slamming food trays, yelling, and threatening residents. The facility failed to recognize these as abuse, delayed reporting to authorities, and inadequately investigated the incidents. CNA #1 was terminated on 10/27/23 after multiple complaints. The facility's response was considered insufficient and delayed, contributing to immediate jeopardy for some residents.
Findings
The facility failed to protect residents from staff-to-resident verbal and mental abuse, failed to timely report and thoroughly investigate abuse allegations, and did not implement effective corrective actions. The facility also failed to maintain proper infection control practices and ensure safe equipment maintenance.
Deficiencies (9)
F 0574: The facility failed to post a sign with how to file a complaint to the State Survey Agency, limiting residents' access to legal rights information.
F 0577: The facility failed to make survey results accessible to residents, family members, and legal representatives in a readily accessible location.
F 0600: The facility failed to protect residents from mental and verbal abuse by CNA #1, creating immediate jeopardy with actual serious harm to some residents.
F 0607: The facility failed to post a conspicuous notice of employee rights under the Elder Justice Act and failed to provide residents and staff with adequate information on abuse reporting.
F 0609: The facility failed to timely report incidents of potential abuse involving four residents to proper authorities and failed to conduct thorough investigations.
F 0610: The facility failed to thoroughly investigate incidents of potential abuse involving five residents and failed to report these incidents to authorities.
F 0867: The facility failed to implement an effective quality assurance program to identify and address concerns related to abuse, reporting, and investigation that caused psychosocial harm.
F 0880: The facility failed to maintain an infection control program by not ensuring proper cleaning practices, isolation precautions, and safe storage of portable oxygen equipment.
F 0908: The facility failed to ensure pellet base heating elements used for meal service were maintained in safe condition, with several elements having large chips that could cause injury.
Report Facts
Sample residents reviewed: 42
Residents affected by abuse allegations: 6
Disciplinary notice date: 2023
Termination date: 2023
Disinfectant surface time: 10
Chips in heating elements: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Named in multiple abuse allegations and disciplinary actions |
| Nursing Home Administrator | NHA | Interviewed regarding abuse investigations and facility responses |
| Director of Nursing | DON | Interviewed regarding abuse reporting and infection control |
| Housekeeping Supervisor | HSKS | Interviewed regarding cleaning procedures and disinfectant use |
| Dietary Director | DD | Interviewed regarding chipped heating elements |
| Regional Resource Nurse | RRN | Provided policies and interviewed about infection control and abuse reporting |
| Social Services Director | SSD | Interviewed regarding abuse reporting and resident interviews |
Inspection Report
Routine
Deficiencies: 3
Date: Jul 27, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to wound care, medication administration, and medical record documentation at the Healthcare Resort of Colorado Springs.
Findings
The facility failed to provide wound care as ordered for one resident, had a medication error rate exceeding 5% for two residents, and allowed licensed nursing staff to document wound care treatments that were not performed.
Deficiencies (3)
F 0684: The facility failed to provide wound care as ordered by the physician for Resident #36, with dressings not changed daily as required.
F 0759: The facility failed to ensure medication error rates were less than 5%, with two medication errors out of 25 opportunities for Residents #28 and #67.
F 0842: The facility failed to ensure licensed nursing staff did not document wound care treatment that had not been provided for Resident #36.
Report Facts
Medication error rate: 8
Medication errors: 2
Medication administration opportunities: 25
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Failed to perform dressing change and documented wound care that was not done for Resident #36 |
| RN #2 | Registered Nurse | Administered incorrect cranberry capsule strength to Resident #67 |
| MA #1 | Medication Aide | Administered incorrect vitamin D dose to Resident #28 |
| LPN #1 | Licensed Practical Nurse | Removed dressing from Resident #36 and revealed dressing dated 07/22/2022 |
| Director of Nursing | Director of Nursing | Provided expectations regarding wound care and medication administration |
| Administrator | Administrator | Provided expectations regarding wound care and medication administration accuracy |
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