D69

KIOWA HILLS REHABILITATION AND NURSING, LLC

Grade D 69/100 composite score

For profit - Limited Liability company

CMS Star Ratings

Overall
1/5
Health Insp.
1/5
Quality
4/5
Staffing
1/5
RN Staffing
Not rated

Certified Beds

83

Ownership

For profit - Limited Liability company

Total Fines

None

Last Survey

N/A

924 W KIOWA ST, COLORADO SPRINGS, CO 80905
7196365221

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Staffing Hours & Turnover

Hours per Resident per Day (PBJ)

RN
0.64h
LPN
0.77h
CNA
1.58h
Total
2.99h
Facility
State Average

Turnover Rates

RN Turnover
N/A
Total Nurse Turnover
N/A
Admin Turnover
N/A

Ownership

CHARLY BELLO FAMILY LIMITED PARTNERSHIP

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Sep 2024

40%

MAZE FAMILY LIMITED PARTNERSHIP

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Sep 2024

50%

PICKD LLC

Organization5% OR GREATER DIRECT OWNERSHIP INTERESTSince Sep 2024

10%

MAHRT, DAVID

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Sep 2024

MYERS, KATIE

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Sep 2024

24%

MYERS, WALTER

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Sep 2024

SWAIN, HOLLY

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Sep 2024

SWAIN, JARED

Individual5% OR GREATER INDIRECT OWNERSHIP INTERESTSince Sep 2024

20%

COTTONWOOD HEALTHCARE LLC

OrganizationOPERATIONAL/MANAGERIAL CONTROLSince Jan 2025

BENNION, DEVAN

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2024

MYERS, WALTER

IndividualOPERATIONAL/MANAGERIAL CONTROLSince Sep 2024

Penalties & Fines

No penalties or fines on record.

Health Inspection Deficiencies (63)

August 27, 2025Health7 deficiencies
0565EMinimal harm, Pattern

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Corrected Oct 6, 2025
0600DMinimal harm, Isolated

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Corrected Oct 6, 2025
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Oct 6, 2025
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Oct 6, 2025
0803EMinimal harm, Pattern

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

Corrected Oct 6, 2025
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Oct 6, 2025
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 6, 2025
January 16, 2025Health13 deficiencies1 severe
0550DMinimal harm, Isolated

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Feb 14, 2025
0553EMinimal harm, Pattern

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Resident Rights Deficiencies

Corrected Feb 14, 2025
0561DMinimal harm, Isolated

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Rights Deficiencies

Corrected Feb 14, 2025
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Feb 14, 2025
0585DMinimal harm, Isolated

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Corrected Feb 14, 2025
0658EMinimal harm, Pattern

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies

Corrected Feb 14, 2025
0679DMinimal harm, Isolated

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Feb 14, 2025
0680EMinimal harm, Pattern

Ensure the activities program is directed by a qualified professional.

Quality of Life and Care Deficiencies

Corrected Feb 14, 2025
0689GActual harm, Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 14, 2025
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Feb 14, 2025
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Feb 14, 2025
0849DMinimal harm, Isolated

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Administration Deficiencies

Corrected Feb 14, 2025
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Feb 14, 2025
December 7, 2023Health17 deficiencies
0565EMinimal harm, Pattern

Honor the resident's right to organize and participate in resident/family groups in the facility.

Resident Rights Deficiencies

Corrected Feb 28, 2024
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Feb 28, 2024
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Feb 28, 2024
0726EMinimal harm, Pattern

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Nursing and Physician Services Deficiencies

Corrected Feb 28, 2024
0742DMinimal harm, Isolated

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Quality of Life and Care Deficiencies

Corrected Feb 28, 2024
0758EMinimal harm, Pattern

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Pharmacy Service Deficiencies

Corrected Feb 28, 2024
0760EMinimal harm, Pattern

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies

Corrected Feb 28, 2024
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Feb 28, 2024
0804FMinimal harm, Widespread

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Feb 28, 2024
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Feb 28, 2024
0838EMinimal harm, Pattern

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Administration Deficiencies

Corrected Feb 28, 2024
0849DMinimal harm, Isolated

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Administration Deficiencies

Corrected Feb 28, 2024
0880DMinimal harm, Isolated

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Feb 28, 2024
0923EMinimal harm, Pattern

Have enough outside ventilation via a window or mechanical ventilation, or both.

Environmental Deficiencies

Corrected Feb 28, 2024
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Feb 28, 2024
0867FMinimal harm, Widespread

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Administration Deficiencies

Corrected Feb 28, 2024
0925EMinimal harm, Pattern

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies

Corrected Feb 28, 2024
September 18, 2023Health4 deficiencies
0550EMinimal harm, Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Corrected Oct 21, 2023
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Oct 12, 2023
0812FMinimal harm, Widespread

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies

Corrected Oct 12, 2023
0925FMinimal harm, Widespread

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies

Corrected Oct 12, 2023
August 25, 2022Health22 deficiencies
0553EMinimal harm, Pattern

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Resident Rights Deficiencies

Corrected Sep 28, 2022
0554DMinimal harm, Isolated

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Corrected Sep 28, 2022
0563EMinimal harm, Pattern

Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.

Resident Rights Deficiencies

Corrected Sep 28, 2022
0584EMinimal harm, Pattern

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.

Resident Rights Deficiencies

Corrected Sep 28, 2022
0659DMinimal harm, Isolated

Provide care by qualified persons according to each resident's written plan of care.

Resident Assessment and Care Planning Deficiencies

Corrected Sep 28, 2022
0677DMinimal harm, Isolated

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0679DMinimal harm, Isolated

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0684DMinimal harm, Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0687DMinimal harm, Isolated

Provide appropriate foot care.

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0688EMinimal harm, Pattern

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0689EMinimal harm, Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0690DMinimal harm, Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0691DMinimal harm, Isolated

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0692DMinimal harm, Isolated

Provide enough food/fluids to maintain a resident's health.

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0695DMinimal harm, Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Corrected Sep 28, 2022
0761EMinimal harm, Pattern

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.

Pharmacy Service Deficiencies

Corrected Sep 28, 2022
0804EMinimal harm, Pattern

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Nutrition and Dietary Deficiencies

Corrected Sep 28, 2022
0849DMinimal harm, Isolated

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Administration Deficiencies

Corrected Sep 28, 2022
0880FMinimal harm, Widespread

Provide and implement an infection prevention and control program.

Infection Control Deficiencies

Corrected Sep 28, 2022
0886FMinimal harm, Widespread

Perform COVID19 testing on residents and staff.

Infection Control Deficiencies

Corrected Sep 28, 2022
0888FMinimal harm, Widespread

Ensure staff are vaccinated for COVID-19

Infection Control Deficiencies

Corrected Sep 28, 2022
0921DMinimal harm, Isolated

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Environmental Deficiencies

Corrected Sep 28, 2022

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Frequently Asked Questions

What is the CareGrader rating for KIOWA HILLS REHABILITATION AND NURSING, LLC?

KIOWA HILLS REHABILITATION AND NURSING, LLC in COLORADO SPRINGS, Colorado has a CareGrader grade of D (Below Average), with a composite score of 69.3 out of 100. This grade is based on health inspections, staffing levels, quality measures, and penalty history from official CMS government data.

What is the CMS star rating for KIOWA HILLS REHABILITATION AND NURSING, LLC?

KIOWA HILLS REHABILITATION AND NURSING, LLC has an overall CMS star rating of 1 out of 5, a health inspection rating of 1/5, and a staffing rating of 1/5. CareGrader combines this with additional data to calculate an A-F grade.

How many health deficiencies does KIOWA HILLS REHABILITATION AND NURSING, LLC have?

KIOWA HILLS REHABILITATION AND NURSING, LLC has 63 health deficiencies on record from CMS health inspection surveys. Deficiencies are rated from A (minimal harm potential) to L (immediate jeopardy, widespread). View the full inspection timeline above for details on each deficiency.

How many beds does KIOWA HILLS REHABILITATION AND NURSING, LLC have?

KIOWA HILLS REHABILITATION AND NURSING, LLC has 83 certified beds with approximately 70 current residents (84% occupancy). The facility is located at 924 W KIOWA ST, COLORADO SPRINGS, Colorado 80905. It is a for profit - limited liability company facility.

Data Disclaimer

Inspection data, staffing levels, and star ratings are sourced from CMS Medicare Nursing Home Compare and are largely self-reported by facilities. A 2019 GAO study found that 43% of facilities under-reported falls. CareGrader provides this data for informational purposes only and is not affiliated with CMS or Medicare. Always visit facilities in person before making a decision.