The Healthcare Resort of Colorado Springs
2818 Grand Vista Cir, Colorado Springs, CO 80904 · El Paso County · 97 certified beds · avg 93 residents/day · certified since Aug 12, 2016
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Nov 8, 2023 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Dec 7, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (21)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jun 26, 2025 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 26, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to make their own choices about their daily lives, such as when to wake up, what to eat, or how to spend their time. |
| Jun 26, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not provide timely, quality laboratory tests to meet residents' needs. |
| Jun 26, 2025 | D · Potential for harm, one-off | The facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. |
| Nov 8, 2023 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not give residents important notices in a format and language they can understand — for example, translated documents or accessible formats for those with vision or hearing loss. |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not develop and follow policies and procedures to prevent abuse, neglect, and theft. These written safeguards are the foundation of resident protection. |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Nov 8, 2023 | E · Potential for harm, repeated | The facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. |
| Nov 8, 2023 | C · Minimal risk, facility-wide | The facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman. |
| Jul 27, 2022 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. |
| Jul 27, 2022 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Jul 27, 2022 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (9 → 9).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 3 | 0 | D |
| 2023 | 9 | 1 | K ▲ |
| 2025 | 9 | 0 | F |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $79,098.
| Date | Type | Amount / length |
|---|---|---|
| Nov 8, 2023 | Fine | $79,098 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Colorado avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.50 | 3.89 | 3.95 | top 19% in Colorado; top 23% in the U.S. |
| Registered Nurse hours | 0.91 | 0.86 | 0.69 | top 34% in Colorado; top 20% in the U.S. |
| Weekend total nurse staffing | 3.75 | 3.44 | 3.50 | top 26% in Colorado; top 31% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.56 | 0.61 | 0.48 | top 46% in Colorado; top 27% in the U.S. |
| Total nursing staff turnover (%) | 54.3 | 47.1 | 45.8 | bottom 27% in Colorado; bottom 26% in the U.S. |
| RN turnover (%) | 36.8 | 44.6 | 42.9 | top 34% in Colorado; top 41% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.80, RN 0.97, weekend 4.00. Staffing rating: 4/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Endura Healthcare LLC | Organization | Direct Ownership Interest | NOT APPLICABLE | 04/14/2014 |
| The Ensign Group INC | Organization | Indirect Ownership Interest | NOT APPLICABLE | 04/14/2014 |
| Burnam, Soon | Individual | Corporate Officer | NOT APPLICABLE | 04/14/2014 |
| Dunyon, David | Individual | Managing Control - Governing Body | NOT APPLICABLE | 08/14/2017 |
| Dunyon, David | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Dunyon, David | Individual | Operational/Managerial Control | NOT APPLICABLE | 08/14/2017 |
| Dunyon, David | Individual | ADP of the SNF | NOT APPLICABLE | 06/12/2025 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 04/14/2014 |
| Jorgensen, David | Individual | Corporate Director | NOT APPLICABLE | 04/14/2014 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Port, Barry | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 06/12/2025 |
| Sato, Ami | Individual | Corporate Officer | NOT APPLICABLE | 09/09/2024 |
| Schultz, Kari | Individual | Managing Control - Governing Body | NOT APPLICABLE | 11/01/2015 |
| Schultz, Kari | Individual | ADP of the SNF | NOT APPLICABLE | 06/12/2025 |
| Welltower Colorado Properties LLC | Organization | ADP of the SNF | NOT APPLICABLE | 04/15/2014 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Center at Centennial, the | 0.8 mi | Colorado Springs, CO | ★★★★★ | 4/5 | |
| Springs Village Care Center | 1.1 mi | Colorado Springs, CO | ★★☆☆☆ | 2/5 | |
| Gardens, the | 1.9 mi | Colorado Springs, CO | ★★★★★ | 5/5 | |
| Sundance Skilled Nursing and Rehabilitation | 2.0 mi | Colorado Springs, CO | ★★☆☆☆ | 2/5 | |
| Bear Creek Senior Living | 2.5 mi | Colorado Springs, CO | ★★★★☆ | 4/5 | |
| Kiowa Hills Rehabilitation and Nursing, LLC | 2.5 mi | Colorado Springs, CO | ★☆☆☆☆ | 1/5 | |
| Colonial Rehabilitation and Nursing, LLC | 2.7 mi | Colorado Springs, CO | ★☆☆☆☆ | 2/5 | abuse |
| Brookdale Skyline | 3.0 mi | Colorado Springs, CO | ★★★★★ | 3/5 | |
| Pikes Peak Post Acute | 3.2 mi | Colorado Springs, CO | ★☆☆☆☆ | 1/5 | abuse |
| Medallion Post Acute Rehabilitation | 3.7 mi | Colorado Springs, CO | ★☆☆☆☆ | 1/5 | |
| Sunny Vista Living Center | 4.2 mi | Colorado Springs, CO | ★★★☆☆ | 3/5 | |
| Advanced Health Care of Colorado Springs | 4.7 mi | Colorado Springs, CO | ★★★★★ | 5/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 065417.