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| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D12 | E6 | F6 |
| Minimal | A· | B· | C· |
CMS publishes about the three most recent standard surveys plus complaint and infection-control inspections from the prior three years. Older findings leave the dataset; their absence is not evidence they never happened.
Federal certification and the state license are different records. A nursing home is licensed by the state and, separately, certified by CMS to bill Medicare and/or Medicaid. We link them by the CCN when the state publishes it; otherwise by exact address, house number and street, or exact name within the same ZIP, and label that link as inferred. Never by name alone.
| Date | Domain | Survey types | Citations | Most severe | Open | |
|---|---|---|---|---|---|---|
| Mar 6, 2025 | Fire safety | Fire Safety Standard | 4 | Potential harm | — | Open → |
| Mar 6, 2025 | Health | Health Complaint, Health Standard | 5 | Potential harm | — | Open → |
| Nov 30, 2023 | Health | Health Complaint | 2 | Potential harm | — | Open → |
| Aug 17, 2023 | Fire safety | Fire Safety Standard | 0 | No citations | — | Open → |
| Aug 17, 2023 | Health | Health Standard | 10 | Potential harm | — | Open → |
| Aug 15, 2019 | Fire safety | Fire Safety Standard | 0 | No citations | — | Open → |
| Aug 15, 2019 | Health | Health Standard | 3 | Potential harm | — | Open → |
| Severity | Isolated | Pattern | Widespread |
|---|---|---|---|
| Immediate jeopardy | J· | K· | L· |
| Actual harm | G· | H· | I· |
| Potential harm | D12 | E6 | F6 |
| Minimal | A· | B· | C· |
| Date | Tag | Deficiency | Scope / severity | Correction | Flags |
|---|---|---|---|---|---|
| Mar 6, 2025 | E-0001 | Establish an Emergency Preparedness Program (EP). Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 5, 2025 | |
| Mar 6, 2025 | E-0015 | Address subsistence needs for staff and patients. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 5, 2025 | |
| Mar 6, 2025 | E-0036 |
“Corrected” does not erase a citation: the historical finding stays listed with its disposition. Narrative statements of deficiencies are not part of the CMS dataset; see Care Compare for the official inspection report.
CMS ratings apply to CMS-certified nursing homes only and are relative within each state. They are not a guarantee of any individual resident’s experience.
CMS legal business name of the certified provider. Operates this facility only.
18 facilities in 9 states. CMS chain ID 151.
Chain average overall rating (CMS): 2.7
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Commonspirit Health | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Nov 28, 2023 |
| Name | Type | Role (Carefield group) | CMS role text | Share | Since |
|---|---|---|---|---|---|
| Commonspirit Health | Organization | Direct owner | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% | Nov 28, 2023 |
| Commonspirit Mountain Region | Organization | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Nov 28, 2023 |
| Debra Carpenter | Individual | Operational / managerial control | OPERATIONAL/MANAGERIAL CONTROL | not provided | Nov 28, 2023 |
| Thomas Mcginn | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 28, 2023 |
Coordinates as published by CMS.
| Facility | Distance | Beds | CMS overall | Last inspection | Citations (window) | Fines |
|---|---|---|---|---|---|---|
| The Center at Centennial 3490 Centennial Blvd, Colorado Springs, CO 80907 CCN 065390 | 7.5 km | 80 | Oct 23, 2024 | 373 harm | — | |
| The Healthcare Resort of Colorado Springs 2818 Grand Vista Cir, Colorado Springs, CO 80904 CCN 065417 | 8.8 km | 97 | Jun 26, 2025 | 281 IJ | $79k | |
| The Gardens 104 Lois Ln, Colorado Springs, CO 80904 CCN 065198 | 9.9 km | 45 | Dec 11, 2025 | 215 open | — | |
| Springs Village Care Center 110 W Van Buren St, Colorado Springs, CO 80907 CCN 065247 | 9.9 km | 91 | Jan 6, 2026 | 573 harm1 open | — | |
| Liberty Heights 12205 Gunstock Dr, Colorado Springs, CO 80921 CCN 065305 | 10.2 km | 42 | Apr 15, 2026 | 381 IJ2 open | $25k | |
| Colonial Rehabilitation and Nursing, LLC 1340 E Fillmore St, Colorado Springs, CO 80907 CCN 065225Abuse icon | 10.7 km | 80 | Mar 9, 2026 | 533 harm | — | |
| Sundance Skilled Nursing and Rehabilitation 2612 W Cucharras St, Colorado Springs, CO 80904 CCN 065152 | 11.1 km | 68 | Feb 26, 2026 | 481 IJ | $15k | |
| Pikes Peak Post Acute 2719 N Union Blvd, Colorado Springs, CO 80909 CCN 065415Abuse icon | 11.6 km | 210 | Aug 20, 2026 | 503 harm2 open | $40k |
| Source | Record | Facts | Evidence | Source release | Retrieved |
|---|---|---|---|---|---|
| CMS Provider Information US-CMS | 065325 | name, address, phone, certification, certified_beds, ownership_type, legal_business_name, chain | Verified | Oct 1, 2026 | Nov 7, 2026 |
| CMS Provider Information US-CMS | 065325 | ratings, staffing, health_survey_score Five-Star ratings and PBJ staffing apply to the CMS-certified universe only. | Verified | Oct 1, 2026 | Nov 7, 2026 |
First seen by Carefield Nov 7, 2026 · last changed Nov 7, 2026. This record as JSON · Report a correction
| Establish emergency prep training and testing. Emergency Preparedness Deficiencies · Emergency preparedness |
| F · Potential harm Widespread |
| Corrected Apr 5, 2025 |
| Mar 6, 2025 | E-0039 | Conduct testing and exercise requirements. Emergency Preparedness Deficiencies · Emergency preparedness | F · Potential harm Widespread | Corrected Apr 5, 2025 |
| Mar 6, 2025 | F-0600 | 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 · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 5, 2025 | Complaint |
| Mar 6, 2025 | F-0622 | Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Apr 5, 2025 | Complaint |
| Mar 6, 2025 | F-0730 | Observe each nurse aide's job performance and give regular training. Nursing and Physician Services Deficiencies · Staffing & supervision | E · Potential harm Pattern | Corrected Apr 5, 2025 |
| Mar 6, 2025 | F-0761 | 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 · Medication management | D · Potential harm Isolated | Corrected Apr 5, 2025 |
| Mar 6, 2025 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | D · Potential harm Isolated | Corrected Apr 5, 2025 |
| Nov 30, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Jan 5, 2024 | Complaint |
| Nov 30, 2023 | F-0882 | Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. Infection Control Deficiencies · Infection prevention | F · Potential harm Widespread | Corrected Jan 17, 2024 | Complaint |
| Aug 17, 2023 | F-0563 | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Nov 15, 2023 |
| Aug 17, 2023 | F-0600 | 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 · Resident rights & abuse/neglect | D · Potential harm Isolated | Corrected Sep 28, 2023 |
| Aug 17, 2023 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 16, 2023 |
| Aug 17, 2023 | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 16, 2023 |
| Aug 17, 2023 | F-0726 | 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 · Staffing & supervision | D · Potential harm Isolated | Corrected Sep 16, 2023 |
| Aug 17, 2023 | F-0744 | Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. Quality of Life and Care Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 16, 2023 |
| Aug 17, 2023 | F-0804 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Sep 16, 2023 |
| Aug 17, 2023 | F-0806 | Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | E · Potential harm Pattern | Corrected Oct 30, 2023 |
| Aug 17, 2023 | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Food, nutrition & hydration | F · Potential harm Widespread | Corrected Sep 16, 2023 |
| Aug 17, 2023 | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · Infection prevention | E · Potential harm Pattern | Corrected Sep 16, 2023 |
| Aug 15, 2019 | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 18, 2019 |
| Aug 15, 2019 | F-0658 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · Clinical care | D · Potential harm Isolated | Corrected Sep 18, 2019 |
| Aug 15, 2019 | F-0676 | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. Quality of Life and Care Deficiencies · Clinical care | E · Potential harm Pattern | Corrected Sep 18, 2019 |
Reported from Payroll-Based Journal (PBJ) data, as published by CMS. Case-mix adjusted total: 4.90 (case-mix index 1.12).
| Mitch Melfi | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 28, 2023 |
| Daniel Morissette | Individual | Corporate officer / director | CORPORATE DIRECTOR | not provided | Nov 28, 2023 |
| Thomas Donohoe | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Nov 28, 2023 |
| Andrew Gaasch | Individual | Corporate officer / director | CORPORATE OFFICER | not provided | Nov 28, 2023 |
| Almaz Behre | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | Nov 28, 2023 |
| David Shepherd | Individual | Managing employee | W-2 MANAGING EMPLOYEE | not provided | Nov 28, 2023 |