Falcon Heights Rehabilitation and Nursing LLC
1795 Monterey Rd, Colorado Springs, CO 80910 · All homes in Colorado Springs
Falcon Heights Rehabilitation and Nursing LLC, a 107-bed for profit - corporation nursing facility in Colorado Springs, CO, holds a 2-star CMS overall rating - below the 3.0-star national average, with nurse staffing below the national norm. 4 inspection findings reached the actual-harm or immediate-jeopardy level.
CMS combines health inspections, nurse-staffing levels, and clinical quality measures into the overall star rating, read the components below; they often tell a sharper story than the headline.
Phone: 7194717850
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- 2 / 5
- Below average · CMS overall · nat'l 3.0
- 2.94
- Well below average · nurse hrs/day · nat'l 3.89
- 36
- Inspection findings · 4 serious
- $6K
- Federal penalties (1)
Health Inspection
Staffing
Quality Measures
Long-Stay Quality
Facility Information
- Provider Number
- 065168
- Ownership
- For profit - Corporation
- Provider Type
- Medicare and Medicaid
- Beds
- 107
- Residents
- 88
- In Hospital
- No
- County
- El Paso
- Last Inspection
- Jul 31, 2024
Staffing Data
How the 2.94 total nursing hours per resident-day are staffed:
- RN Hours
- 0.62 (nat'l avg: 0.68)
- LPN Hours
- 0.48
- CNA Hours
- 1.84
- Total Nursing Hours
- 2.94 (nat'l avg: 3.89)
- PT Hours
- 0.07
- Nursing Turnover
- 73.2%
- RN Turnover
- 77.3%
What the CMS Record Reveals About Falcon Heights Rehabilitation and Nursing LLC
Falcon Heights Rehabilitation and Nursing LLC operates 107 certified beds in Colorado Springs, CO with approximately 88 residents currently in care, and carries a CMS overall rating of 2 out of 5 stars (health inspection 2★ · staffing 1★ · quality 5★).
The inspection file contains 36 deficiency records from recent surveys, of which 4 reached the actual-harm or immediate-jeopardy threshold on the CMS scope-and-severity grid. This provider has been fined 1 time by CMS, for a combined $6K. Staffing is reported at 2.94 total nursing hours per resident day (national average 3.89), with RN coverage at 0.62 per resident day.
Classified as "For profit - Corporation" ownership and operating as a "Medicare and Medicaid" provider, Falcon Heights Rehabilitation and Nursing LLC falls into a category where comparative context matters. Reported nursing turnover at this facility is 73.2%, above the level where continuity of care typically begins to suffer.
Why sub-scores and the CMS methodology matter
The overall score is a composite of three weighted sub-ratings published by the Centers for Medicare & Medicaid Services: health inspection results, staffing levels, and quality measures. Because CMS caps the overall score at the health-inspection tier and then adjusts up or down based on staffing and quality, the sub-scores often tell a sharper story than the headline star count alone, a 3-star facility with weak inspection history reads differently from one held back by thin staffing.
National research consistently shows that ownership structure, staffing hours, and turnover are the three operational levers that correlate most strongly with resident outcomes, ratings and fines are lagging indicators of those upstream choices. The staffing metric in particular is the one most strongly tied to resident outcomes in peer-reviewed literature.
For families evaluating this facility, the CMS record should be read alongside a site visit, direct conversation with current residents and their families, and review of the state health department's most recent inspection report, the star rating is a starting point, not a verdict. All data on this page is sourced from CMS Provider Data and the Nursing Home Compare program; always verify details directly with the facility or your state survey agency before making placement decisions.
Deficiency History (36 most recent)
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Dec 2, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Feb 28, 2025
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
Category: Resident Rights Deficiencies
Corrected: Nov 8, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Oct 30, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 28, 2024
Honor the resident's right to choose his or her attending physician.
Category: Resident Rights Deficiencies
Corrected: Aug 28, 2024
Have enough outside ventilation via a window or mechanical ventilation, or both.
Category: Environmental Deficiencies
Corrected: Aug 28, 2024
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Aug 28, 2024
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 28, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Category: Nutrition and Dietary Deficiencies
Corrected: Aug 28, 2024
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.
Category: Pharmacy Service Deficiencies
Corrected: Aug 28, 2024
Ensure medication error rates are not 5 percent or greater.
Category: Pharmacy Service Deficiencies
Corrected: Aug 28, 2024
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 28, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 28, 2024
Provide activities to meet all resident's needs.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 28, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Aug 28, 2024
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Aug 28, 2024
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.
Category: Resident Rights Deficiencies
Corrected: Aug 28, 2024
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Category: Resident Rights Deficiencies
Corrected: Aug 28, 2024
Respond appropriately to all alleged violations.
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
Corrected: Mar 18, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Category: Quality of Life and Care Deficiencies
Corrected: Mar 18, 2023
Perform COVID19 testing on residents and staff.
Category: Infection Control Deficiencies
Corrected: Dec 18, 2021
Provide and implement an infection prevention and control program.
Category: Infection Control Deficiencies
Corrected: Dec 18, 2021
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
Category: Administration Deficiencies
Corrected: Dec 18, 2021
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Category: Nutrition and Dietary Deficiencies
Corrected: Dec 18, 2021
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 18, 2021
Provide safe, appropriate pain management for a resident who requires such services.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 18, 2021
Provide safe and appropriate respiratory care for a resident when needed.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 18, 2021
Provide enough food/fluids to maintain a resident's health.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 18, 2021
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 18, 2021
Provide care and assistance to perform activities of daily living for any resident who is unable.
Category: Quality of Life and Care Deficiencies
Corrected: Dec 18, 2021
Ensure services provided by the nursing facility meet professional standards of quality.
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 18, 2021
PASARR screening for Mental disorders or Intellectual Disabilities
Category: Resident Assessment and Care Planning Deficiencies
Corrected: Dec 18, 2021
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Category: Resident Rights Deficiencies
Corrected: Dec 18, 2021
Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing.
Category: Resident Rights Deficiencies
Corrected: Dec 18, 2021
Allow residents to self-administer drugs if determined clinically appropriate.
Category: Resident Rights Deficiencies
Corrected: Dec 18, 2021
Quality Measures
| Measure | Type | Score | Used in Rating |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased | Long Stay | 13.2% | Yes |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | Long Stay | 0.4% | Yes |
| Percentage of long-stay residents with a urinary tract infection | Long Stay | 1.6% | Yes |
| Percentage of long-stay residents experiencing one or more falls with major injury | Long Stay | 3.3% | Yes |
| Percentage of long-stay residents whose ability to walk independently worsened | Long Stay | 15.8% | Yes |
| Percentage of long-stay residents with pressure ulcers | Long Stay | 0.7% | Yes |
| Percentage of long-stay residents who received an antipsychotic medication | Long Stay | 34.3% | Yes |
| Percentage of short-stay residents who newly received an antipsychotic medication | Short Stay | 9.1% | Yes |
| Percentage of long-stay residents who lose too much weight | Long Stay | 1.5% | No |
| Percentage of long-stay residents who have depressive symptoms | Long Stay | 16.9% | No |
| Percentage of long-stay residents who were physically restrained | Long Stay | 0.0% | No |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | Long Stay | 93.1% | No |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | Long Stay | 10.3% | No |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | Long Stay | 97.5% | No |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | Long Stay | 15.4% | No |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | Short Stay | 49.1% | No |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | Short Stay | 64.7% | No |
Penalty History 1 penalties totaling $6K
| Date | Type | Amount |
|---|---|---|
| Sep 24, 2024 | Fine | $6K |
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Understanding Nursing Home Data
Frequently Asked Questions
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Data Sources
Data source: CMS Nursing Home Compare. Ratings, staffing, deficiency, quality measure, and penalty data are from CMS Provider Data. For informational purposes only. Always verify information directly with the facility or your state health department.
Read our methodology - how this data is sourced, computed, and verified.
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