Kiowa Hills Rehab: Incontinence Care Delays - CO
The incident at Kiowa Hills Rehabilitation and Nursing involved Resident #11, a patient with a history of venous stasis ulcers who required total assistance from staff for repositioning and incontinence care. Federal inspectors found the facility failed to provide timely care on August 26, 2025.
CNA #2 told inspectors she changed Resident #11 at 6:00 a.m. that morning. After the patient finished breakfast, she asked if he wanted to be changed again, and he refused. The aide said she typically provided incontinence care between 9:30 and 9:45 a.m., but "because he had refused, no care was provided."
The aide intended to provide care after lunch but discovered hospice workers had already changed and repositioned the patient, so she didn't have to.
When hospice CNA #1 arrived that day, the worker found Resident #11's brief "saturated with urine and his skin was wet in the perineal area." Hospice staff visited the facility twice weekly on Tuesdays and Fridays to give the patient bed baths, while facility staff handled daily incontinence care and repositioning.
Resident #11's care plan documented both bowel and bladder incontinence. His positioning plan noted he preferred lying on his back with feet elevated on pillows. Interventions included frequent repositioning for pressure relief, a pressure-reducing mattress, and total staff assistance for turning as needed or requested.
The facility's bowel and bladder care plan, revised May 28, 2025, required checking and changing the resident frequently, on request, and as needed for incontinence. Staff were supposed to change clothing after incontinence episodes and provide total assistance.
LPN #1 explained facility policy during the inspection: residents should be repositioned every two hours, and incontinence care should be provided every two hours. The nurse said CNAs should perform skin checks during incontinence care.
"Resident #11 was at risk for developing pressure ulcers as he was not mobile," LPN #1 told inspectors. The nurse confirmed the patient did not currently have pressure ulcers.
CNA #2 acknowledged the care requirements during her interview. She said residents should be repositioned and receive incontinence care every two hours. "If residents were not repositioned or changed, they could develop a bed sore or pressure ulcers," she told inspectors.
The aide received reeducation on August 26 about providing timely incontinence care and repositioning.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. The complaint-based inspection occurred on August 27, 2025.
Resident #11's vulnerability made the care lapse particularly concerning. His medical history of venous stasis ulcers and immobility put him at heightened risk for developing pressure wounds without consistent repositioning and skin care.
The facility's care plan emphasized the importance of frequent intervention, including assistance with repositioning "often as needed or requested" and incontinence care "after each incontinence episode, or per an established toileting plan."
Hospice CNA #1's discovery of saturated conditions highlighted the gap in care between the 6:00 a.m. change and the hospice worker's arrival hours later. The timing suggested the patient remained in wet conditions for an extended period despite facility policies requiring two-hour intervals.
The incident raised questions about how staff handle patient refusals for necessary care. While Resident #11 declined the morning change, his incontinence and immobility meant extended periods without care posed health risks.
CNA #2's explanation that she skipped the usual 9:30-9:45 a.m. care because of the patient's refusal suggested staff may need additional training on managing care refusals while protecting resident safety.
The hospice arrangement created a shared care responsibility, with outside workers providing twice-weekly baths while facility staff handled daily needs. This coordination required clear communication about who provided what care when.
Resident #11's preference for back positioning with elevated feet, combined with his incontinence and immobility, created a care scenario requiring vigilant attention to prevent skin breakdown and pressure injuries.
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 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
KIOWA HILLS REHABILITATION AND NURSING, LLC in COLORADO SPRINGS, CO was cited for violations during a health inspection on August 27, 2025.
Federal inspectors found the facility failed to provide timely care on August 26, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.