Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
KIOWA HILLS REHABILITATION AND NURSING, LLC
COLORADO SPRINGS, CO · 83 certified beds · Last Life Safety survey January 16, 2025
CMS Certification Number 065175 · first certified July 1981
Ownership
Operated by THE CHARLY BELLO FAMILY, THE MAZE FAMILY, THE SWAIN FAMILY, & WALTER MYERS · For profit - Limited Liability company
- Ownership changed September 1, 2024 (change of ownership)from KIOWA HILLS HEALTH AND REHABILITATION CENTER LLC
Position within CO
34 citations — more than 93% 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 18 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window is open now: June 2026 to January 2027. This facility’s last Life Safety survey was January 2025. 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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7 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.
Emergency preparedness
4 of the 34 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
13 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 34 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.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
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 | 34 |
| Median facility in CO | 16 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| August 25, 2022 | 7 |
| December 7, 2023 | 9 |
| January 16, 2025 | 18 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 3 | 2025-01-16 |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | 3 | 2025-01-16 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 3 | 2025-01-16 |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | 2 | 2025-01-16 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2025-01-16 |
| K-0324 | Provide properly protected cooking facilities. | 2 | 2025-01-16 |
| K-0914 | Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | 2 | 2025-01-16 |
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2025-01-16 |
What the citations cover
- Smoke Deficiencies 11
- Gas, Vacuum, and Electrical Systems Deficiencies 7
- Egress Deficiencies 5
- Services Deficiencies 5
- Other 6
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 7 |
| Egress Deficiencies | 5 |
| Services Deficiencies | 5 |
| Emergency Preparedness Deficiencies | 4 |
| Miscellaneous Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 16, 2025 — 18 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0001 | Establish an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (February 14, 2025) |
| E-0039 | Conduct testing and exercise requirements. | Deficient, Provider has date of correction (February 14, 2025) |
| 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. | Waiver has been granted (June 1, 2026) |
| K-0225 | Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Deficient, Provider has date of correction (March 15, 2025) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 15, 2025) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (March 15, 2025) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Deficient, Provider has date of correction (March 15, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (June 1, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 15, 2025) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 15, 2025) |
| K-0500 | Meet other general requirements that are deficient. | Deficient, Provider has date of correction (March 15, 2025) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (March 15, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (March 15, 2025) |
| K-0531 | Have elevators that firefighters can control in the event of a fire. | Waiver has been granted (January 1, 2027) |
| 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 (March 15, 2025) |
| 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 (March 15, 2025) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (August 1, 2026) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (March 15, 2025) |
December 7, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0037 | Establish staff and initial training requirements. | Deficient, Provider has date of correction (February 28, 2024) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (March 4, 2024) |
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (January 25, 2024) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (June 1, 2024) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (April 1, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (March 4, 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 (March 1, 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 (March 19, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (January 1, 2025) |
August 25, 2022 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0030 | List the names and contact information of those in the facility. | Deficient, Provider has date of correction (September 28, 2022) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (November 15, 2022) |
| K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. | Waiver has been granted (June 30, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Waiver has been granted (June 30, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (November 15, 2022) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Waiver has been granted (June 30, 2023) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (November 15, 2022) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.