Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
COLONIAL REHABILITATION AND NURSING, LLC
COLORADO SPRINGS, CO · 80 certified beds · Last Life Safety survey August 31, 2023
CMS Certification Number 065225 · first certified December 1985
Ownership
Operated by THE CHARLY BELLO FAMILY, THE MAZE FAMILY, THE SWAIN FAMILY, & WALTER MYERS · For profit - Limited Liability company
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within CO
14 citations — more than 39% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 2.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Well past the typical window (February 2025 to September 2025), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was August 2023. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 14 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0584 Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
How that compares
Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 14 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 15, 2018 | 3 |
| October 16, 2019 | 2 |
| August 31, 2023 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 2 | 2023-08-31 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 2 | 2023-08-31 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2023-08-31 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 1 | 2018-11-15 |
| K-0324 | Provide properly protected cooking facilities. | 1 | 2023-08-31 |
| K-0712 | Have simulated fire drills held at unexpected times. | 1 | 2023-08-31 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2018-11-15 |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | 1 | 2023-08-31 |
What the citations cover
- Smoke Deficiencies 6
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Miscellaneous Deficiencies 2
- Egress Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 6 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Services Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 31, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Waiver has been granted (March 19, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (October 21, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (October 21, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (November 30, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Past Non-Compliance (August 31, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (October 21, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (October 21, 2023) |
| K-0917 | Ensure electrical receptacles or cover plates have distinctive color or marking. | Deficient, Provider has date of correction (October 21, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 21, 2023) |
October 16, 2019 — 2 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (December 2, 2019) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (November 25, 2019) |
November 15, 2018 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (January 22, 2019) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (January 22, 2019) |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Deficient, Provider has date of correction (January 22, 2019) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.