Kiowa Hills Rehabilitation And Nursing, Llc

F 0565 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

grievance form for any concerns voiced by the residents. She said she then distributed the form to the appropriate department. She said the department head then wrote a response to the grievance of how it would be resolved. She said the facility has had numerous complaints regarding the food. She said the facility recently hired a new dietary manager. She said the food grievances were not resolved and continued to be an issue. She said the response for a resolution needed to be received within 72 hours. The NHA was interviewed on 8/27/25 at approximately 12:00 p.m. The NHA said he had worked at the facility for the past month. He said he was aware there were food complaints and he had recently hired a new dietary manager with good experience to help improve the dining department. He said grievances should be followed up within 72 hours. He said that he was slowly chipping away at issues brought up from the resident council.

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Facility ID:

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

incident, including CNA #1, who confirmed that Resident #3 approached and grabbed Resident #2’s arm. He said other nearby staff did not witness the incident directly, but reported that Resident #3 appeared restless earlier in the day. The NHA said no other facility residents observed the incident.

The NHA said the facility’s internal investigation determined that the abuse allegation incident was substantiated. He said CNA #1 directly observed Resident #3 grab Resident #2’s arm. He said no injuries occurred with the incident and skin assessments were performed on Resident #2. He said appropriate interventions, including enhanced supervision and medical work-up were implemented by the facility.

The NHA said during the interview with Resident #3, she was unable to provide a clear or coherent explanation of the incident. He said due to her cognitive impairment, her responses were determined by the facility to be disorganized and did not align with the events that occurred. The NHA said the facility determined through the interview with Resident #3 that she was not of sound mind and unable to participate in a meaningful interview.

The NHA said the DON met with Resident #3 and Resident #2 on 6/8/25 about the events that occurred.

He said Resident #3 was unable to recall any events due to her cognitive impairment. Resident #2 was unable to communicate the events, due to her aphasia and underlying cognitive impairment.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

integrity. Resident #11 had a history of venous stasis ulcers. Resident #11 preferred to be positioned on his back with his feet elevated on pillows. Interventions included assisting Resident #11 to reposition and/or turn at frequent intervals to provide pressure relief, providing a pressure reducing mattress on his bed, providing total assistance from staff to turn/reposition often as needed or requested and providing incontinence care after each incontinence episode, or per an established toileting plan.The bowel and bladder care plan, revised 5/28/25, documented Resident #11 had both bowel and bladder incontinence.

Interventions included checking and changing the resident frequently, on request and as required for incontinence, changing clothing as needed after incontinence episodes and providing total assistance from staff.II. Staff interviewsHospice CNA #1 was interviewed on 8/26/25 at 1:25 p.m. Hospice CNA #1 said that

the hospice CNAs came to the facility two days a week on Tuesday and Fridays and gave Resident #11 a bed bath. Hospice CNA #1 said that the staff from the facility was responsible for providing incontinence care and repositioning for Resident #11 when the hospice staff were not there.Hospice CNA #1 was interviewed a second time on 8/26/25 at 1:47 p.m. Hospice CNA #1 said when removing Resident #11's brief it was saturated with urine and his skin was wet in the perineal area.LPN #1 was interviewed on 8/26/25 at 1:50 p.m. LPN #1 said residents should be repositioned every two hours. LPN #1 said incontinence care should be provided every two hours. LPN #1 said CNAs should be doing a skin check when providing incontinence care. LPN #1 said Resident #11 was at risk for developing pressure ulcers as

he was not mobile. LPN #1 said Resident #11 did not currently have any pressure ulcers.CNA #2 was interviewed on 8/27/25 at 1:19 pm. CNA #2 said residents should be repositioned and provided incontinence care every two hours. CNA #2 said if residents were not repositioned or changed, they could develop a bed sore or pressure ulcers.CNA #2 said she provided repositioning and incontinence care for Resident #11. CNA #2 said she changed Resident #11 on 8/26/25 at 6:00 a.m. She said after Resident #11 ate his breakfast, she asked him if he wanted to be changed and he said no. She said she usually changed Resident #11 between 9:30 a.m. and 9:45 a.m., but because he had refused, no care was provided. She said she had intended to provide incontinence care and repositioning for Resident #11 after lunch but said that the hospice CNAs had already changed Resident #11 and repositioned him so she did not have to.

She said she received reeducation on 8/26/25 on providing timely incontinence care and repositioning.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm

with calcium alginate, which was a fibrous material used to collect exudate. He said the calcium alginate got thicker and a little more soggy when exudate leaked from the wound and got absorbed into the alginate material. He said the alginate helped absorb exudate and honey helped to soften hard tissues, so he changed the physician's order to xeroform gauze. -However, Resident #4 did not have xeroform gauze on her wounds during the wound observation (see observations and LPN #2's interview above).

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

extensions above).The DM said when he first started at the facility one of the residents requested chicken strips off the alternative menu. The DM said they were out of chicken strips, so he went and talked to the resident and offered them something else. The DM said he had a stock of everything on the alternative menu so that he does not run out again. The DM said he recently made updated changes to the alternative menu known as the bistro menu. He said he added more options for the residents to choose from.The NHA was interviewed on 8/27/25 at 1:41 p.m. The NHA said the DM and cooks should be following recipes when preparing the meals for the residents. The NHA said there were recipes in the dining manager RD. The NHA said not following the recipes could be concerning for allergies, safety concerns and nutritional values.

The NHA said he would make sure to educate the DM on where to find and print out the recipes.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

interviewsThe dietary manager (DM) was interviewed on 8/27/25 10:50 a.m. The DM said hot food should be at 135 degrees F and cold food at 41 degrees or below. The DM said his goal was to have the cold food at 36 degrees F. The DM said the potato salad should have been placed in smaller containers and on ice to keep it within the correct temperature range. The DM said the reason why they were not placed in smaller containers was because he did not have enough smaller containers. The DM said he did not have enough pans to put ice under the pan. The DM said he placed an order for supplies with the NHA. The DM said there was not a cooling spot in the satellite kitchen to place cold items in. The DM said the potato salad should not have been so high. The DM said the potato salad was cooling in the refrigerator for over four hours and did not understand why the temperature was high.The NHA was interviewed on 8/27/25 at 1:41 p.m. The NHA said the DM gave him some invoices for things to be ordered. The NHA said he would talk with the DM and see what he needed ordered for the kitchen.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/27/2025

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

trays for the 300 hall were passed out. The cart had four room trays. The plate had a dome cover over the food, however, the oatmeal on the trays were not covered as it was transported down the hallway. C. Staff interviewThe DM was interviewed on 8/27/25 at 10:50 a.m. The DM said the staff should change their gloves between tasks. He said if the CK was handling only buns, they would not need to change their gloves. The DM said the unidentified DA should have changed her gloves after putting her hand in the bag of chips. The DM said the unidentified DA should not have used her hand to get the hamburger patty out of

the pan. The DM said the unidentified DA should have used tongs. The DM said he would provide education to the staff on hand hygiene. II. Failure to ensure food was held at the correct temperatureA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/4/25. It revealed in pertinent part, Time/Temperature control for safety food, hot and cold holding at 135 degrees F (Fahrenheit) or higher and 41 degrees F and lower. (Chapter 3)B. ObservationsDuring a continuous observation during the dinner meal on 8/26/25, beginning at 5:05 p.m. and ending at 6:00 p.m., the following was observed:At 5:11 p.m.

an unidentified DA took the temperature of the potato salad and it was 49 degrees F. The potato salad was stored on a cart and was not on ice during the meal service. C. Staff interviewsThe DM was interviewed on 8/27/25 10:50 a.m. The DM said hot food should be held at 135 degrees F and cold food at 41 degrees F

during meal service. The DM said the potato salad should not have been 49 degrees F. The DM said the potato salad should have been placed in smaller pans. The DM said the satellite kitchen did not have a cooling spot to put cold items in. The DM said the potato salad should have been placed on ice, but they did not have enough pans.III. Failure to ensure food was covered during transportation from the kitchen to the residents' roomsA. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/4/25. It revealed in pertinent part, Food shall be protected from contamination that may result from a factor or source. (Chapter 3).B. ObservationsOn 8/26/25 at 9:16 a.m. the room trays for the 600 hall were being passed out to the residents. The cart had four room trays. The plate had a dome cover over the food. The oatmeal and apple sauce on the trays were not covered as it was transported down the hallway. C. Staff interviewsThe DM was interviewed on 8/27/25 at 10:50 a.m. The DM said when room trays were delivered,

the food on the tray should be covered. The DM said he did not have covers for the bowls and cups. He said

he talked to the NHA about not having bowl and cup covers. He said the nursing home administrator (NHA) said they would purchase those items in September 2025. He said he also did not have enough room tray covers. He said there were a lot of residents who ate in their rooms. The NHA was interviewed on 8/27/25 at 1:41 p.m. The NHA said the kitchen should have covers for the bowls and cups. The NHA said he was not aware that the kitchen did not have covers for the bowls and cups. The NHA said bowls and cups should be covered due to sanitization and temperature control. The NHA said he was working with the DM about what was needed in the kitchen.The NHA said he would get them ordered as soon as possible. He said he would talk to the DM and see what needed to be ordered.

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Facility ID:

If continuation sheet