Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
FALCON HEIGHTS REHABILITATION AND NURSING LLC
COLORADO SPRINGS, CO · 107 certified beds · Last Life Safety survey July 31, 2024
CMS Certification Number 065168 · first certified July 1982
Ownership
Operated by THE CHARLY BELLO FAMILY, THE MAZE FAMILY, THE SWAIN FAMILY, & WALTER MYERS · For profit - Corporation
- New ownershipOwnership changed September 1, 2025 (change of ownership)from FALCON HEIGHTS HEALTH AND REHABILITATION CENTER LLC
Position within CO
26 citations — more than 81% 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 8.5. 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 (January 2026 to August 2026), and past the point by which nine in ten CO facilities have been surveyed. This facility’s last Life Safety survey was July 2024. 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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8 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)
5 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 26 Life Safety citations above. The Physical Environment Index
- 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.
- 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-0923 Have enough outside ventilation via a window or mechanical ventilation, or both.
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 | 26 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| November 18, 2021 | 6 |
| February 22, 2023 | 11 |
| July 31, 2024 | 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 | 2024-07-31 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2024-07-31 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 2 | 2023-02-22 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2024-07-31 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2024-07-31 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 2 | 2024-07-31 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2023-02-22 |
| K-0293 | Have properly located and lighted "Exit" signs. | 2 | 2024-07-31 |
What the citations cover
- Smoke Deficiencies 11
- Egress Deficiencies 5
- Services Deficiencies 5
- Gas, Vacuum, and Electrical Systems Deficiencies 4
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Egress Deficiencies | 5 |
| Services Deficiencies | 5 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 4 |
| Miscellaneous Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 31, 2024 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Waiver has been granted (November 1, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 25, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 18, 2024) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (August 28, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (August 28, 2024) |
| 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 (September 20, 2024) |
February 22, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Deficient, Provider has date of correction (April 3, 2023) |
| K-0293 | Have properly located and lighted "Exit" signs. | Deficient, Provider has date of correction (April 3, 2023) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (April 3, 2023) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (September 30, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (September 30, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (April 3, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (April 6, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 30, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (April 12, 2023) |
| 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 (April 12, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (April 13, 2023) |
November 18, 2021 — 6 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (December 26, 2021) |
| K-0344 | Have an alternate power supply for its alarm system. | Waiver has been granted (June 30, 2022) |
| K-0363 | Install corridor and hallway doors that block smoke. | Waiver has been granted (April 8, 2022) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (December 26, 2021) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (January 6, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (December 26, 2021) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.