Kiowa Hills Rehab: Resident-on-Resident Attack - CO
The June incident involved two residents who could not provide coherent accounts of what happened. Resident #3, who has cognitive impairment, approached and grabbed Resident #2's arm while a certified nursing assistant watched. The facility's administrator told inspectors that Resident #2 suffers from aphasia and underlying cognitive impairment that prevented her from communicating about the events.
CNA #1 directly observed the incident and confirmed to investigators that Resident #3 grabbed Resident #2's arm. Other staff members nearby did not witness the grabbing directly, but reported that Resident #3 had appeared restless earlier that day, according to the nursing home administrator.
The administrator said no other facility residents observed the incident.
Following the grabbing, the facility conducted skin assessments on Resident #2 and determined no injuries occurred. The nursing home implemented what it called "appropriate interventions," including enhanced supervision and a medical work-up for the resident who initiated the contact.
When facility staff interviewed Resident #3 about the incident, she could not provide a clear explanation of what happened. The administrator told inspectors that due to her cognitive impairment, her responses were "disorganized and did not align with the events that occurred." The facility determined through the interview that Resident #3 "was not of sound mind and unable to participate in a meaningful interview."
The director of nursing met with both residents on June 8 to discuss the incident. Resident #3 was unable to recall any events due to her cognitive impairment, while Resident #2 could not communicate about what happened because of her aphasia and cognitive issues.
The facility's internal investigation concluded that the abuse allegation was substantiated based on the direct observation by the nursing assistant.
Federal inspectors cited the nursing home for failing to ensure residents were free from abuse, finding the facility at fault for not preventing the incident despite having staff present who witnessed it occur.
The inspection, conducted in response to a complaint, documented the facility's handling of an incident involving two of its most vulnerable residents, both unable to advocate for themselves or provide meaningful accounts of their experiences.
The citation carries a designation of "minimal harm or potential for actual harm" affecting few residents, according to the federal inspection report. The facility received the violation under federal regulation F 0600, which requires nursing homes to protect residents from abuse.
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.
The June incident involved two residents who could not provide coherent accounts of what happened.
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.