COLORADO SPRINGS, CO - Federal inspectors documented serious safety failures at Kiowa Hills Rehabilitation and Nursing, where staff repeatedly left call lights out of reach for a high-risk resident who had previously suffered a femur fracture in a fall while attempting to get water.
The January 16, 2025 inspection revealed multiple violations affecting resident safety, medication management, food safety, and infection control at the 924 W Kiowa Street facility.
Critical Safety Failures for Fall-Risk Resident
The most concerning finding involved an 80-year-old resident with dementia and a history of fractures who was left without access to emergency assistance. Resident #38, who had moderate cognitive impairment and required supervision for basic activities, experienced a witnessed fall on December 20, 2024, while trying to walk to her sink for water. The fall resulted in a fractured right femur requiring surgical repair.
Despite her documented high fall risk and recent serious injury, inspectors found staff consistently failed to keep her call light within reach over multiple days. During a two-hour continuous observation period on January 13, the call light button remained under her pillow above her head, completely out of sight and reach, while staff members entered and left the area without checking its placement.
Medical Significance of Call Light Access
Call lights serve as a critical safety mechanism in nursing homes, particularly for residents with mobility limitations and cognitive impairment. When residents cannot summon help, they may attempt unsafe transfers or movements that can result in serious injuries. For residents with dementia, the inability to access assistance can lead to confusion, agitation, and dangerous attempts at self-care.
Falls represent one of the most serious risks in nursing home settings, with hip fractures carrying significant mortality and morbidity rates among elderly residents. Proper supervision and immediate access to assistance are essential preventive measures, especially for residents who have already experienced fall-related injuries.
The facility's own fall care plan specified that staff should anticipate and meet the resident's needs, keep the call light within reach, and encourage its use. However, implementation of these basic safety protocols was inconsistent despite the resident's documented high-risk status.
Medication Safety Violations Compromise Care Quality
Inspectors found multiple expired medications throughout the facility's medication storage areas and carts. Expired medications discovered included:
- Antidepressant medications with expiration dates from September and November 2024 - Blood pressure medication expired in October 2024 - Medical grade honey wound treatment expired in December 2024 - A dietary supplement expired in April 2024
Risks of Expired Medications
Using expired medications poses significant health risks to nursing home residents. Pharmaceutical compounds can lose potency over time, potentially rendering treatments ineffective when residents need them most. Certain medications, particularly antibiotics and heart medications, may develop harmful compounds as they degrade.
For elderly residents with multiple chronic conditions, medication effectiveness is crucial for maintaining health and preventing complications. Reduced potency in blood pressure medications could lead to cardiovascular events, while ineffective antibiotics might allow infections to progress unchecked.
The facility also failed to properly label over-the-counter medications with resident names, creating risks of medication errors and cross-contamination between residents.
Food Safety Lapses Create Infection Risks
The kitchen and food service areas presented multiple contamination hazards that could lead to foodborne illnesses among vulnerable residents. Inspectors observed dietary staff using the same gloves for multiple tasks without changing them, including handling raw produce, touching faucets, and preparing ready-to-eat foods.
During lunch service observation, staff members handled serving utensils, meal tickets, and resident food items with the same gloves throughout extended periods. One dietary aide used contaminated gloves to handle hot dog buns and cookies served directly to residents.
Food Safety Standards and Health Implications
Professional food safety standards require single-use gloves to prevent cross-contamination between different food preparation tasks. When staff handle multiple surfaces and food items with the same gloves, bacteria and contaminants can transfer between items, potentially causing foodborne illnesses.
Nursing home residents face heightened risks from foodborne pathogens due to age-related immune system changes and underlying health conditions. Gastrointestinal infections can lead to dehydration, electrolyte imbalances, and serious complications requiring hospitalization.
Additional food safety violations included expired items in refrigerators, unlabeled and undated prepared foods, and improper meat thawing procedures that could promote bacterial growth.
Infection Control Deficiencies During COVID-19 Precautions
Despite having residents with active COVID-19 infections requiring droplet precautions, facility staff repeatedly entered isolation rooms without required eye protection. The isolation supply cart outside one affected room lacked the eye protection specified on the door signage.
The facility also failed to offer updated 2024-2025 COVID-19 vaccinations to residents, with documentation showing some residents had not received updated vaccines since December 2023. This represents a significant gap in protection for a highly vulnerable population.
Infection Control Standards in Long-Term Care
Proper infection control measures are essential in nursing homes where residents live in close proximity and may have compromised immune systems. Transmission-based precautions serve as barriers to prevent disease spread between residents and to healthcare workers.
COVID-19 continues to pose serious risks to elderly nursing home residents, with higher rates of severe illness, hospitalization, and death compared to younger populations. Updated vaccinations provide crucial protection against evolving virus variants.
Poor hand hygiene practices observed during meal delivery compound infection risks, as staff moved between resident rooms without proper handwashing, potentially carrying pathogens from room to room.
Hospice Care Coordination Problems
The facility failed to maintain proper coordination with hospice services for a terminally ill resident. Documentation showed missing physician orders for hospice care, absence of required communication binders, and failure to update care plans when the resident changed hospice providers.
This resident reported not seeing a hospice nurse for several weeks, indicating gaps in the comfort care that hospice services are designed to provide during end-of-life care.
Activities Program Lacks Proper Oversight
Federal regulations require nursing homes to provide activities that meet individual resident interests and needs. However, the facility's activities director lacked proper training, supervision, and qualifications for the role.
The activities director, who started January 6, 2025, had no previous experience in activities coordination and was unsure about certification requirements. The initial activity calendar consisted primarily of repetitive coffee and news sessions, representing 50% of scheduled activities.
Regulatory Response and Resident Protection
These violations represent failures in multiple areas of nursing home operations that collectively compromise resident safety and quality of care. Federal regulations exist specifically to protect vulnerable nursing home residents from preventable harm and ensure they receive appropriate medical care, nutrition, and safety oversight.
The facility must submit corrective action plans addressing each violation and demonstrate sustained compliance to avoid potential enforcement actions. Families and potential residents should review inspection reports and visit facilities to assess safety practices before making placement decisions.
For complete details about these violations and the facility's response plans, families can access the full inspection report through the Medicare.gov nursing home compare website or contact the Colorado Department of Public Health and Environment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kiowa Hills Rehabilitation and Nursing, LLC from 2025-01-16 including all violations, facility responses, and corrective action plans.
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