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Health Inspection

Kiowa Hills Rehabilitation And Nursing, Llc

January 16, 2025 · Colorado Springs, CO · 924 W Kiowa St
Citations 2
CMS Rating 1/5
Beds 83
Provider ID 065175
Healthcare Facility
Kiowa Hills Rehabilitation And Nursing, Llc
Colorado Springs, CO  ·  View full profile →
Inspection Summary

KIOWA HILLS REHABILITATION AND NURSING, LLC in COLORADO SPRINGS, CO — inspection on January 16, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF679
Minimal harm or Some development and revision of activity care plans. affected

According to the January 2025 computerized physician orders (CPO), diagnoses included fracture of the neck of the right femur, dementia,

impairments with a brief interview for mental status (BIMS) score of eight out of 15. Resident #38 required supervision or touching assistance with personal hygiene and partial assistance with transfers.

She was independent with mobility in a wheelchair.

The assessment documented Resident #38 had clear speech and was always able to make herself understood.

She was occasionally incontinent of urine and required partial assistance with getting on and off the toilet.

B.

Observations and interview

On 1/12/25 at 5:30 p.m. Resident #38 was lying in bed.

The call light button was on the floor under the head of the bed, out of the resident's sight and reach.

On 1/13/25 at 9:50 a.m. Resident #38 was lying in bed.

The call light was on her pillow above her head, out of her sight.

A continuous observation was conducted on 1/13/25, beginning at 2:09 p.m. and ending at 4:09 p.m.

The following was observed:

At 2:09 p.m. Resident #38 was lying in bed.

The call light button was under the pillow above her head, out of sight and reach.

At 2:35 p.m. an unknown certified nurse aide (CNA) stopped and looked into Resident #38's room, then continued to walk down the hall.

The unidentified CNA did not enter the resident's room to ensure the resident's call light was within her reach.

At 2:50 p.m. an unknown CNA delivered ice water to Resident #38's roommate but did not check the call light placement for Resident #38.

The call light button was still under the pillow above the resident's head.

At 3:42 p.m. the call light button remained under the pillow above her head.

At 4:09 p.m. the call light button remained under Resident #38's pillow above her head.

On 1/13/25 at 4:32 p.m. registered nurse (RN) #1 observed Resident #38's call light placement. RN #1 said call lights should be placed beside the residents where they could reach them. RN #1 said the cord had a clip so it could be clipped to the resident's shirt. RN #1 moved Resident #38's call light from under the pillow to the top of her comforter.

On 1/14/25 at 8:54 a.m. Resident #38 was lying in bed.

The call light cord was clipped to the top corner of the sheet above Resident #38's head.

The call button was on the floor under the head of the bed, out of sight and reach.

065175

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065175 B.

Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

F-F680 for failure to meet the qualifications of an activity professional.

potential for actual harm

065175

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 065175 B.

Wing 01/16/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COLORADO SPRINGS, CO, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from KIOWA HILLS REHABILITATION AND NURSING, LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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