Kiowa Hills Rehab: Wound Care Orders Ignored - CO
That is what inspectors documented at Kiowa Hills Rehabilitation and Nursing on August 26, 2025, when they watched a licensed practical nurse perform wound care on a resident with vascular ulcers on both ankles and one foot. On all three wounds, the nurse skipped a prescribed dressing material. On one of them, she used a material the doctor had specifically moved away from.
The resident, identified in the inspection report as Resident 4, had vascular ulcers that the wound care physician described as wounds that came and went because of circulation problems in her legs. As of August 21, four days before the dressing change the inspectors reviewed and one day before the observation, the physician had ordered the same protocol for all three wounds: cleanse with wound cleanser, apply skin prep to the surrounding skin, place xeroform gauze directly on the wound, and cover with a bordered gauze dressing.
Xeroform gauze, the physician explained, keeps a moist healing environment for the cells and acts as a barrier to protect the wound. He had switched to it from calcium alginate, a fibrous material used to absorb fluid draining from wounds. The alginate, he said, gets thicker and soggier as it absorbs that drainage. He had also been using honey to soften hardened tissue. The new orders replaced all of that.
When the nurse, identified as LPN 2, began the dressing change on the right dorsal foot, inspectors watched her remove a bordered gauze dressing. There was no xeroform gauze beneath it.
She moved to the right medial ankle. That wound had a bordered gauze dressing on it that was slightly saturated and yellow. When she removed it, there was no xeroform gauze beneath that dressing either. Instead, inspectors saw blackish brown material on the wound. LPN 2 said it was calcium alginate buildup that needed to be sprayed, softened, and removed. She peeled the dressing off in pieces because it had become more slimy when exposed to the wound cleanser spray. After cleaning the wound, she applied skin prep and placed xeroform gauze, then covered it with a fresh bordered gauze dressing. But she left the wound without the outer bordered gauze dressing entirely during part of the process, and the inspection report documents that the wound had no bordered gauze covering it at the time of observation.
The left medial ankle wound had a bordered gauze dressing that was slightly saturated. When LPN 2 removed it, there was no xeroform gauze beneath that one either.
After the observation, LPN 2 told inspectors she had not seen xeroform gauze under any of the dressings when she changed them. She acknowledged that it was important to check the physician's orders before changing wound dressings, specifically because this resident's orders changed frequently. She said the calcium alginate on the right medial ankle was buildup that needed to be cleared.
The physician's orders from August 21 did not mention calcium alginate at all.
The facility's treatment records showed all three wound dressings had been documented as changed on August 25 at 9:26 p.m., the night before inspectors watched LPN 2 perform the dressing change. That documentation does not address whether xeroform gauze was applied during that prior change. The inspection report does not resolve what was or was not placed on the wounds before the observation date, only that when inspectors watched the dressings come off, the prescribed material was absent from all three.
The wound care physician, interviewed the following morning, confirmed the current treatment called for xeroform gauze. He confirmed the purpose. He confirmed the prior treatment had used calcium alginate and that he had changed the orders. When told what inspectors had observed, he had no explanation for why the wounds did not have xeroform gauze on them.
Resident 4's care plan noted she had impaired skin integrity and required enhanced barrier precautions to prevent the spread of infection.
The inspection was conducted as a complaint investigation. The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. The facility was given the opportunity to submit a plan of correction.
The wounds were vascular ulcers. They were open. The physician had chosen a specific material to protect them, and he had chosen it recently, with a reason. Four days after he wrote those orders, none of the three wounds had what he prescribed.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 4, 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.
On all three wounds, the nurse skipped a prescribed dressing material.
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.