01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2024-07-31 | 17 | 2024-07-31 | 9 |
| Cycle 2 | 2023-02-22 | 4 | 2023-02-22 | 11 |
| Cycle 3 | 2021-11-18 | 15 | 2021-11-18 | 6 |
CMS CCN 0651682026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Falcon Heights Rehabilitation And Nursing Llc
1795 Monterey Rd · Colorado Springs, CO 80910 · El Paso County
Certified beds107CMS provider file
Recent citation rows62current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
62 rows in the current release
4 rows carry G–L scope/severity codes; 1 carry J–L. 17 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-02-25 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2026-03-20 · complaint2025-12-01 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-12-02 · complaint2025-02-03 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-02-28 · complaint2024-09-24 · HEALTHF0609Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-10-30 · complaint2024-09-24 · HEALTHF0626Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Correction field: Deficient, Provider has date of correction · 2024-11-08 · complaint2024-07-31 · HEALTHF0550Severity G · isolated actual harm
Resident Rights Deficiencies
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0555Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to choose his or her attending physician.
Correction field: Deficient, Provider has date of correction · 2024-08-28 · complaint2024-07-31 · HEALTHF0584Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0679Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2024-08-28 · complaint2024-07-31 · HEALTHF0689Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0697Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe, appropriate pain management for a resident who requires such services.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0759Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0804Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0812Severity F · widespread; potential for more than minimal harm
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · HEALTHF0923Severity E · pattern; potential for more than minimal harm
Environmental Deficiencies
Have enough outside ventilation via a window or mechanical ventilation, or both.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · FIREK0222Severity D · isolated; potential for more than minimal harm
Egress Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · FIREK0293Severity F · widespread; potential for more than minimal harm
Egress Deficiencies
Have properly located and lighted "Exit" signs.
Correction field: Deficient, Provider has date of correction · 2024-08-282024-07-31 · FIREK0324Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Waiver has been granted · 2024-11-012024-07-31 · FIREK0345Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2024-08-2803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-09-24 | Fine | $6,146 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- CHARLY BELLO FAMILY LIMITED PARTNERSHIPOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- MAZE FAMILY LIMITED PARTNERSHIPOrganization · DIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- MAHRT, DAVIDIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- MYERS, KATIEIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- MYERS, WALTERIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- SWAIN, HOLLYIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- SWAIN, JAREDIndividual · INDIRECT OWNERSHIP INTERESTNOT APPLICABLE · since 09/01/2024
- COTTONWOOD HEALTHCARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- ABBOTT, IANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- HOLMES, CAROLYNIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 09/01/2024
- HOLMES, CAROLYNIndividual · ADP OF THE SNFNOT APPLICABLE · since 04/17/2025
- REDDY, VIKASIndividual · ADP OF THE SNFNOT APPLICABLE · since 01/23/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.05per resident day
RN hours0.52per resident day
Weekend nurse hours2.66per resident day
Staff turnover47.9%CMS reported field
06 / LOCAL RECORDS
Open the Colorado Springs ledger →Other published facilities nearby
Advanced Health Care Of Colorado Springs34 beds · CMS overall 5/531 citation rowsBear Creek Senior Living45 beds · CMS overall 4/526 citation rowsBrookdale Skyline82 beds · CMS overall 5/546 citation rowsCenter At Centennial, The80 beds · CMS overall 5/537 citation rowsColonial Rehabilitation And Nursing, Llc80 beds · CMS overall 1/553 citation rowsFountain View Rehabilitation And Nursing Llc90 beds · CMS overall 3/525 citation rowsGardens, The45 beds · CMS overall 5/521 citation rowsKiowa Hills Rehabilitation And Nursing, Llc83 beds · CMS overall 1/598 citation rows