Pikes Peak Post Acute

CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on September 22, 2026.

  CMS has cited this home for F0600 5 times since 2023.

• Citation F0628. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.

  CMS lists it as corrected on September 22, 2026.

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• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on December 19, 2025.

• Citation F0744. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  CMS lists it as corrected on December 19, 2025.

  CMS has cited this home for F0744 2 times since 2023.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5.

• Health citation

  CMS changed citation F0880 from severity D to E. It is from the health inspection on September 5, 2023. Severity E: potential for more than minimal harm, pattern.

• Fire safety citation

  CMS removed citation K0222 from the fire safety inspection on February 20, 2025.

• Fire safety citation

  CMS removed citation K0293 from the fire safety inspection on February 20, 2025.

• Fire safety citation

  CMS removed citation K0324 from the fire safety inspection on February 20, 2025.

• Fire safety citation

  CMS removed citation K0353 from the fire safety inspection on February 20, 2025.

• Fire safety citation

  CMS removed citation K0363 from the fire safety inspection on February 20, 2025.

• Fire safety citation

  CMS removed citation K0372 from the fire safety inspection on February 20, 2025.

• Fire safety citation

  CMS removed citation K0712 from the fire safety inspection on February 20, 2025.

• Fire safety citation

  CMS removed citation K0918 from the fire safety inspection on February 20, 2025.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

• Fine

  CMS changed the fine from September 17, 2024 from $61,410 to $39,917.

• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

CMS lists this as a standard inspection and a complaint inspection.

• Citation F0585. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on February 18, 2025.

• Citation F0730. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Observe each nurse aide's job performance and give regular training.

  CMS lists it as corrected on February 18, 2025.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on February 18, 2025.

• Citation F0561. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on February 18, 2025.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on February 18, 2025.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on February 18, 2025.

• Citation F0685. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assist a resident in gaining access to vision and hearing services.

  CMS lists it as corrected on February 18, 2025.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on February 18, 2025.

  CMS has cited this home for F0689 3 times since 2022.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on February 18, 2025.

  CMS has cited this home for F0880 3 times since 2022.

• Citation F0921. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on February 18, 2025.

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CMS lists this as a standard inspection.

• Citation E0015. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Address subsistence needs for staff and patients.

  CMS lists it as corrected on February 18, 2025.

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• CMS abuse icon

  CMS added its abuse icon to this home.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Changed ownership in the last 12 months

  CMS no longer shows a change of ownership in the past 12 months.

CMS stopped payment for new admissions from October 16, 2024, for 28 days.

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CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

65 of 210 Colorado homes (31%) got a citation at the actual harm level in 2024.

• Citation F0600. Severity G: actual harm, isolated.

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

  CMS lists it as corrected on September 18, 2024.

• Citation F0609. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on November 13, 2024.

• Citation F0610. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Respond appropriately to all alleged violations.

  CMS lists it as corrected on November 13, 2024.

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CMS fine of $39,917 on September 17, 2024.

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• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Ownership

  CMS lists this home under a new chain.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Special Focus Facility

  CMS no longer lists this home as a Special Focus Facility candidate.

• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS lists this home under a new chain.

• Fine

  CMS changed the fine from September 5, 2023 from $76,000 to $49,400.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

• Special Focus Facility

  CMS now lists this home as a Special Focus Facility candidate.

• Changed ownership in the last 12 months

  CMS records show a change of ownership in the past 12 months.

CMS lists this as a complaint inspection.

• Citation F0695. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on April 12, 2024.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Name

  CMS lists a new legal business name for this home.

• Ownership

  CMS no longer lists a chain for this home.

• Staffing

  Total nurse staffing reported to CMS went from 3.1 to 2.2 hours per resident per day.

CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

55 of 210 Colorado homes (26%) got a citation at the actual harm level in 2023.

• Citation F0657. Severity G: actual harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on November 30, 2023.

  CMS has cited this home for F0657 2 times since 2022.

• Citation F0552. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that residents are fully informed and understand their health status, care and treatments.

  CMS lists it as corrected on November 30, 2023.

• Citation F0559. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

  CMS lists it as corrected on November 30, 2023.

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CMS lists this as a standard inspection.

Severity H is the second-highest of CMS's four levels. It means a resident was harmed.

55 of 210 Colorado homes (26%) got a citation at the actual harm level in 2023.

• Citation F0692. Severity H: actual harm, pattern.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on November 7, 2023.

• Citation F0803. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on September 27, 2023.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

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

  CMS lists it as corrected on September 27, 2023.

• Citation F0838. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: 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.

  CMS lists it as corrected on November 15, 2023.

• Citation F0867. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on November 15, 2023.

• Citation F0565. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to organize and participate in resident/family groups in the facility.

  CMS lists it as corrected on November 15, 2023.

• Citation F0567. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Honor the resident's right to manage his or her financial affairs.

  CMS lists it as corrected on September 27, 2023.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 27, 2023.

• Citation F0744. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

  CMS lists it as corrected on November 5, 2023.

• Citation F0759. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on September 27, 2023.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: 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.

  CMS lists it as corrected on December 4, 2023.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on November 15, 2023.

• Citation F0881. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Implement a program that monitors antibiotic use.

  CMS lists it as corrected on September 27, 2023.

• Citation F0554. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Allow residents to self-administer drugs if determined clinically appropriate.

  CMS lists it as corrected on September 27, 2023.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on November 5, 2023.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on November 15, 2023.

• Citation F0676. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

  CMS lists it as corrected on September 27, 2023.

• Citation F0679. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on September 27, 2023.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on November 6, 2023.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: 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.

  CMS lists it as corrected on October 30, 2023.

• Citation F0712. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that the resident and his/her doctor meet face-to-face at all required visits.

  CMS lists it as corrected on September 27, 2023.

• Citation F0806. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

  CMS lists it as corrected on September 27, 2023.

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CMS lists this as a standard inspection.

• Citation F0689. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on July 15, 2022.

• Citation F0645. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: PASARR screening for Mental disorders or Intellectual Disabilities

  CMS lists it as corrected on July 15, 2022.

• Citation F0657. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

  CMS lists it as corrected on July 15, 2022.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on July 15, 2022.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

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

  CMS lists it as corrected on July 15, 2022.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on July 12, 2022.

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