Falcon Heights Rehabilitation And Nursing LLC
Colorado Springs, El Paso County, Colorado · CCN 065168 · For-profit (Corporation) · part of The Charly Bello Family, The Maze Family, The Swain Family, & Walter Myers (19 facilities, chain average 1.7 stars)
CMS rates Falcon Heights Rehabilitation And Nursing LLC 2 of 5 overall as of August 2026. 107 certified beds, 89 residents a day on average. 36 citations on record from the current inspection cycles, 1 at immediate jeopardy; 1 fine totalling $6,146.
On record
- Abuse icon. CMS marks this facility for a citation of abuse that led to harm, or a repeated potential for it, within the recent inspection cycles.
- Changed ownership in the last twelve months.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★★☆☆☆ 2 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★☆☆☆☆ 1 of 5 |
| Quality measures | ★★★★★ 5 of 5 |
| Quality: long-stay / short-stay | 5 / — of 5 |
Staffing
| Total nurse staffing | 3.05385 hours per resident per day |
|---|---|
| Registered nurses | 0.52284 hours per resident per day |
| Weekend total | 2.65964 hours per resident per day |
| Nursing staff turnover | 47.9% (registered nurses 58.8%) |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-02-25 complaint survey |
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 · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-03-20 |
| 2025-12-01 complaint survey |
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 · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-12-02 |
| 2025-02-03 complaint survey |
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 · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-28 |
| 2024-09-24 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-10-30 |
| 2024-09-24 complaint survey |
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. Resident Rights Deficiencies · tag F0626 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-11-08 |
| 2024-07-31 | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. Resident Rights Deficiencies · tag F0550 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. Nutrition and Dietary Deficiencies · tag F0804 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 complaint survey |
Honor the resident's right to choose his or her attending physician. Resident Rights Deficiencies · tag F0555 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | 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 · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | 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 · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | Have enough outside ventilation via a window or mechanical ventilation, or both. Environmental Deficiencies · tag F0923 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | 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 · tag F0600 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | Provide activities to meet all resident's needs. Quality of Life and Care Deficiencies · tag F0679 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-28 |
| 2024-07-31 | Ensure medication error rates are not 5 percent or greater. Pharmacy Service Deficiencies · tag F0759 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-08-28 |
| 2023-02-22 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-03-18 |
| 2021-11-18 | Perform COVID19 testing on residents and staff. Infection Control Deficiencies · tag F0886 |
L Immediate jeopardy to resident health or safety; widespread | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Provide safe, appropriate pain management for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0697 |
G Actual harm that is not immediate jeopardy; isolated | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. Resident Rights Deficiencies · tag F0563 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Ensure services provided by the nursing facility meet professional standards of quality. Resident Assessment and Care Planning Deficiencies · tag F0658 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Administration Deficiencies · tag F0867 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
F No actual harm, with potential for more than minimal harm; widespread | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Allow residents to self-administer drugs if determined clinically appropriate. Resident Rights Deficiencies · tag F0554 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | 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. Resident Rights Deficiencies · tag F0578 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · tag F0677 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Provide enough food/fluids to maintain a resident's health. Quality of Life and Care Deficiencies · tag F0692 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-18 |
| 2021-11-18 | Provide safe, appropriate dialysis care/services for a resident who requires such services. Quality of Life and Care Deficiencies · tag F0698 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2021-12-18 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2024-09-24 | Fine | $6,146 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Charly Bello Family Limited Partnership Organization | direct ownership interest | — | 2024-09-01 |
| Maze Family Limited Partnership Organization | direct ownership interest | — | 2024-09-01 |
| Cottonwood Healthcare LLC Organization | operational/managerial control | — | 2024-09-01 |
| Holmes, Carolyn Individual | adp of the snf | — | 2025-04-17 |
| Reddy, Vikas Individual | adp of the snf | — | 2025-01-23 |
| Mahrt, David Individual | indirect ownership interest | — | 2024-09-01 |
| Myers, Katie Individual | indirect ownership interest | — | 2024-09-01 |
| Myers, Walter Individual | indirect ownership interest | — | 2024-09-01 |
| Swain, Holly Individual | indirect ownership interest | — | 2024-09-01 |
| Swain, Jared Individual | indirect ownership interest | — | 2024-09-01 |
| Abbott, Ian Individual | operational/managerial control | — | 2024-09-01 |
| Holmes, Carolyn Individual | operational/managerial control | — | 2024-09-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for Falcon Heights Rehabilitation And Nursing LLC.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in El Paso County.