Inspection Reports for
Pikes Peak Post Acute
2719 N UNION BLVD, COLORADO SPRINGS, CO, 80909-
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
26.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
415% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
80
60
40
20
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to complaints of resident-to-resident physical abuse incidents involving Residents #1, #2, #3, #4, and #5, and concerns about dementia care services for Resident #3.
Complaint Details
The complaint investigation substantiated incidents of physical abuse by Resident #1 against Residents #2 and #3, and an unsubstantiated incident involving Resident #4 pushing Resident #5 causing a skin tear. The facility failed to prevent these incidents and failed to implement effective interventions to manage aggressive behaviors and wandering.
Findings
The facility failed to protect Residents #2, #3, and #5 from physical abuse by other residents and failed to provide appropriate dementia care services to Resident #3. Multiple incidents of resident-to-resident abuse were substantiated, with minimal harm but potential for actual harm. Staff failed to consistently redirect Resident #3 during wandering and inappropriate behaviors. The facility also failed to implement effective interventions to prevent Resident #4 from entering other residents' rooms and escalating behaviors.
Deficiencies (2)
Failed to protect Residents #2, #3, and #5 from physical abuse by other residents.
Failed to provide appropriate treatment and services to Resident #3 diagnosed with dementia, including failure to provide meaningful redirection and person-centered dementia care.
Report Facts
Residents affected: 3
Skin tear size: 7
BIMS scores: 0
BIMS score: 3
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding incidents and care plans; provided details on Resident #1, #4, and #5 behaviors and facility procedures. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding resident behaviors and incidents; described Resident #1, #2, #3, and #4 behaviors and supervision. |
| DON | Director of Nursing | Interviewed with NHA about substantiation of abuse incidents and interventions implemented. |
| NHA | Nursing Home Administrator | Interviewed with DON about substantiation of abuse incidents and interventions implemented. |
| AD | Activities Director | Interviewed regarding dementia training and activities provided to Resident #3. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Nov 20, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident physical abuse and failure to provide appropriate dementia care at Pikes Peak Post Acute nursing home.
Complaint Details
The complaint investigation substantiated incidents of resident-to-resident physical abuse involving Residents #1, #2, #3, #4, and #5. Resident #1 physically abused Residents #2 and #3. Resident #4 allegedly pushed Resident #5 causing a skin tear. The facility failed to prevent these incidents and failed to implement effective interventions to protect residents. Additionally, the facility failed to provide adequate dementia care for Resident #3.
Findings
The facility failed to protect residents from physical abuse by other residents, substantiating incidents involving Residents #1, #2, #3, #4, and #5. The facility also failed to provide appropriate dementia care and person-centered interventions for Resident #3, resulting in inadequate redirection and supervision.
Deficiencies (2)
F 0600: The facility failed to protect residents #2, #3, and #5 from physical abuse by other residents, with substantiated incidents of slapping, hitting, and pushing causing injury or risk of harm.
F 0744: The facility failed to provide appropriate treatment and services to Resident #3 with dementia, including failure to implement effective person-centered dementia care approaches and meaningful redirection.
Report Facts
Skin tear size: 7
BIMS score: 3
BIMS score: 0
BIMS score: 0
BIMS score: 3
BIMS score: 9
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding incidents of abuse and care plans for residents involved in physical altercations. |
| CNA #1 | Certified Nurse Aide | Interviewed regarding observations of resident behaviors and incidents of abuse. |
| DON | Director of Nursing | Interviewed regarding substantiation of abuse incidents and facility interventions. |
| NHA | Nursing Home Administrator | Interviewed regarding facility policies, substantiation of abuse incidents, and dementia care training. |
| AD | Activities Director | Interviewed regarding dementia training and activities provided to residents. |
Inspection Report
Routine
Deficiencies: 10
Date: Jan 30, 2025
Visit Reason
The inspection was a routine regulatory survey to assess compliance with federal regulations for nursing home care.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs, failure to honor resident self-determination, inadequate grievance handling, failure to protect residents from abuse, inadequate assistance with activities of daily living, failure to provide timely vision services, inadequate supervision to prevent falls, failure to conduct annual CNA performance reviews, and deficiencies in infection control and environmental safety.
Deficiencies (10)
F 0558: The facility failed to ensure Resident #26's bed side rails were installed as requested and recommended, limiting mobility and independence.
F 0561: The facility failed to promote and facilitate a room change for Resident #30 per her preference, delaying resolution of roommate concerns.
F 0585: The facility failed to maintain a system to document and promptly resolve grievances for Residents #135, #40, #37, and #51.
F 0600: The facility failed to protect Residents #88 and #54 from physical abuse by Resident #144, and failed to implement updated interventions to prevent further altercations.
F 0677: The facility failed to provide complete grooming and bathing assistance to Residents #48 and #77, including shaving, hair washing, and nail care.
F 0685: The facility failed to ensure Resident #137 received new eyeglasses in a timely manner despite a prescription and representative requests.
F 0689: The facility failed to ensure adequate supervision and adherence to fall prevention interventions for Resident #4, resulting in multiple falls and unassisted ambulation with unsafe footwear.
F 0730: The facility failed to complete annual performance reviews and provide in-service education for CNAs #4, #5, and #6.
F 0880: The facility failed to maintain an infection control program by not ensuring housekeeping staff wore gloves and performed hand hygiene, wore masks properly during a flu outbreak, and sanitized dining tables and floors between meals.
F 0921: The facility failed to maintain kitchen equipment in a safe and sanitary condition, including unresolved leaks under sinks and broken floor tiles causing water accumulation.
Report Facts
Residents reviewed: 53
Residents affected: 1
Residents affected: 1
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 1
Residents affected: 1
CNAs without annual review: 3
Units with infection control deficiencies: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #26 bed rails issue |
| RN #3 | Registered Nurse | Interviewed regarding Resident #26 bed rails issue |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #26 bed rails issue |
| Physical Therapy Assistant (PTA) | Interviewed regarding Resident #26 bed rails issue | |
| Occupational Therapist (OT) | Interviewed regarding Resident #26 bed rails issue | |
| Assistant Director of Rehabilitation (ADOR) | Interviewed regarding Resident #26 bed rails issue | |
| Director of Nursing (DON) | Interviewed regarding Resident #26 bed rails and other deficiencies | |
| Social Services Director (SSD) | Interviewed regarding grievance handling and Resident #137 eyeglasses | |
| Certified Nurse Aide (CNA) #7 | Witnessed resident altercations involving Resident #144 | |
| Licensed Practical Nurse (LPN) #2 | Assessed residents after altercations involving Resident #144 | |
| Certified Nurse Aide (CNA) #8 | Interviewed regarding Resident #144 behaviors | |
| Certified Nurse Aide (CNA) #9 | Interviewed regarding Resident #144 behaviors | |
| Licensed Practical Nurse (LPN) #3 | Interviewed regarding bathing and grooming care | |
| Dietary Manager (DM) | Interviewed regarding dining room cleaning and kitchen maintenance | |
| Housekeeping Supervisor (HKS) | Interviewed regarding housekeeping practices | |
| Housekeeper (HK) #1 | Observed and interviewed regarding housekeeping deficiencies | |
| Maintenance Director (MTD) | Interviewed regarding kitchen maintenance and work order system | |
| Nursing Home Administrator (NHA) | Interviewed regarding kitchen maintenance and work order system | |
| Regional Director of Clinical Services (RDCS) | Interviewed regarding multiple deficiencies and follow up |
Inspection Report
Routine
Deficiencies: 3
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to assess the facility's infection prevention and control program and to evaluate compliance with housekeeping and dining area sanitation standards during a flu outbreak.
Findings
The facility failed to maintain an effective infection control program, specifically housekeeping staff did not wear gloves or perform proper hand hygiene, wore masks improperly during a flu outbreak, and staff failed to sanitize dining tables and floors between meals. Observations and interviews confirmed these deficiencies across multiple units.
Deficiencies (3)
Housekeeping staff failed to wear gloves and perform appropriate hand hygiene while cleaning residents' rooms.
Housekeeping staff wore masks improperly during a flu outbreak.
Staff failed to sanitize dining tables and floors prior to the next meal.
Report Facts
Residents affected: 3
Dining tables observed: 5
Residents observed in dining room: 4
Residents observed in dining room: 3
Residents observed in dining room: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HK #1 | Housekeeper | Observed failing to wear gloves, perform hand hygiene, and wearing mask improperly during flu outbreak |
| HKS | Housekeeping Supervisor | Interviewed regarding housekeeping staff glove use and hand hygiene expectations |
| IP | Infection Preventionist | Interviewed regarding infection control practices and mask use |
| DM | Dietary Manager | Interviewed about dining room cleaning responsibilities and cleaning logs |
Inspection Report
Routine
Deficiencies: 3
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program and compliance with sanitation standards during a flu outbreak.
Findings
The facility failed to maintain an effective infection control program, including housekeeping staff not wearing gloves or performing proper hand hygiene, improper mask use during a flu outbreak, and failure to sanitize dining tables and floors between meals.
Deficiencies (3)
F 0880: The facility failed to ensure housekeeping staff wore gloves and performed appropriate hand hygiene while cleaning residents' rooms, including handling mopheads and trash without gloves or hand hygiene.
F 0880: Housekeeping staff wore masks improperly during a flu outbreak, with one staff member observed wearing a mask under her nose.
F 0880: Staff failed to sanitize dining tables and floors between meals, with multiple observations of food crumbs, stains, and debris remaining on tables and floors throughout the day.
Report Facts
Residents affected: 3
Dining tables: 5
Residents observed in dining room: 4
Residents observed in dining room: 3
Residents observed in dining room: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| HK #1 | Housekeeper | Named in multiple infection control and hygiene failures |
| HKS | Housekeeping Supervisor | Interviewed regarding housekeeping staff hygiene and glove use |
| IP | Infection Preventionist | Interviewed regarding infection control practices and mask use |
| DM | Dietary Manager | Interviewed regarding dining room cleaning responsibilities and schedules |
Inspection Report
Routine
Deficiencies: 10
Date: Jan 30, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, and facility operations, including investigations of complaints and review of care plans and environment.
Findings
The facility was found deficient in multiple areas including failure to accommodate resident needs for bed rails, failure to honor resident room change preferences, inadequate grievance documentation and follow-up, failure to protect residents from abuse, inadequate assistance with activities of daily living, delayed provision of eyeglasses, insufficient supervision to prevent falls, lack of annual performance reviews for CNAs, infection control lapses including improper housekeeping practices and failure to sanitize dining areas, and unsafe kitchen conditions due to leaks and water accumulation.
Deficiencies (10)
Failed to provide requested bed side rails for Resident #26 to accommodate mobility and independence.
Failed to promote, facilitate and support a room change for Resident #30 per her preference.
Failed to maintain a system of documenting grievances and demonstrating prompt action for residents #135, #40, #37 and #51.
Failed to protect Residents #88 and #54 from physical abuse by Resident #144.
Failed to provide complete grooming including shaving, hair washing and nail trimming for Residents #48 and #77.
Failed to ensure Resident #137's new eyeglasses were obtained in a timely manner.
Failed to ensure adequate supervision and adherence to fall prevention interventions for Resident #4.
Failed to complete annual performance reviews and provide in-service education for CNAs #4, #5 and #6.
Failed to maintain infection control practices including improper glove use by housekeeping, improper mask use during flu outbreak, and failure to sanitize dining tables and floors between meals.
Failed to maintain kitchen equipment in safe, sanitary and working condition including unresolved leaks and water accumulation under sinks.
Report Facts
Residents reviewed: 53
Number of showers received: 6
Number of bed baths received: 7
Number of falls: 2
Number of residents affected by grievance system failure: 4
Number of residents affected by abuse incident: 2
Number of CNAs without annual review: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #26 bed rail needs |
| RN #3 | Registered Nurse | Interviewed regarding Resident #26 bed rail needs |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #26 bed rail requests |
| Physical Therapy Assistant (PTA) | Interviewed regarding Resident #26 bed rail benefits | |
| Occupational Therapist (OT) | Interviewed regarding Resident #26 bed rail requests | |
| Assistant Director of Rehabilitation (ADOR) | Interviewed regarding bed rail request process | |
| Director of Nursing (DON) | Interviewed regarding bed rail request and Resident #26 care | |
| Social Services Director (SSD) | Interviewed regarding grievances and Resident #30 room change | |
| Certified Nurse Aide (CNA) #7 | Witness to resident to resident abuse incidents | |
| Licensed Practical Nurse (LPN) #2 | Assessed residents after abuse incidents | |
| Dietary Manager (DM) | Interviewed regarding dining room cleaning | |
| Housekeeper (HK) #1 | Observed and interviewed regarding housekeeping practices | |
| Housekeeping Supervisor (HKS) | Interviewed regarding housekeeping practices | |
| Infection Preventionist (IP) | Interviewed regarding infection control practices | |
| Maintenance Director (MTD) | Interviewed regarding kitchen leaks and repairs | |
| Nursing Home Administrator (NHA) | Interviewed regarding maintenance work orders | |
| Regional Director of Clinical Services (RDCS) | Interviewed regarding eyeglasses and CNA performance reviews |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 17, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse and failure to properly investigate and report incidents of abuse involving multiple residents.
Complaint Details
The complaint investigation was substantiated. The facility failed to prevent physical abuse by Resident #1 toward other residents and failed to investigate and report these incidents to the State Survey Agency as required by law.
Findings
The facility failed to protect residents from physical and verbal abuse by Resident #1 toward other residents, including Resident #2, #8, #9, and #10. The facility also failed to conduct timely investigations and report incidents of abuse to the State Survey Agency as required. Resident #1 exhibited repeated aggressive behaviors over several months, and the facility did not implement effective person-centered interventions to prevent further abuse.
Deficiencies (3)
F 0600: The facility failed to protect residents from physical and verbal abuse by Resident #1 toward multiple residents, including Resident #2 and Resident #8, resulting in actual harm.
F 0609: The facility failed to timely report suspected abuse and the results of investigations to proper authorities for incidents involving Residents #1, #2, and #9.
F 0610: The facility failed to investigate incidents of physical aggression involving Resident #1, including multiple incidents on 7/8/24, 7/20/24, and 8/8/24.
Report Facts
Physical abuse incidents by Resident #1 toward Resident #2: 4
Physical abuse incidents by Resident #1 toward multiple residents: 8
Residents reviewed for abuse: 10
Residents affected by abuse: 4
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Sep 17, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of abuse involving multiple residents, specifically focusing on incidents of physical and verbal abuse by Resident #1 toward other residents.
Complaint Details
The complaint investigation focused on abuse allegations involving Resident #1 physically assaulting multiple residents, including Residents #2, #8, #9, and #10. The facility failed to investigate or report these incidents properly. The investigation found multiple unaddressed incidents of abuse and inadequate interventions to prevent recurrence.
Findings
The facility failed to prevent multiple incidents of physical abuse by Resident #1 toward other residents, including Resident #2 and Resident #8, and failed to conduct timely investigations or report these incidents to the State Survey Agency. The facility also failed to implement effective person-centered interventions to prevent further abuse and did not adequately monitor or manage Resident #1's aggressive behavior.
Deficiencies (3)
Failure to protect residents from physical and verbal abuse by Resident #1, resulting in multiple incidents of actual harm.
Failure to timely report alleged abuse incidents involving Resident #1 to the State Survey Agency.
Failure to investigate incidents of physical abuse involving Resident #1.
Report Facts
Residents reviewed for abuse: 10
Residents affected by abuse: 4
Physical abuse incidents by Resident #1: 8
Physical assaults on Resident #2 by Resident #1: 4
Medication dosages: 1
Medication dosages: 50
Medication dosages: 100
Medication dosages: 25
Resident weight: 240
BIMS score: 0
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Clinical Consultant | Interviewed regarding abuse investigations and reporting | |
| Director of Nursing (DON) | Interviewed regarding Resident #1's behavior and facility response | |
| Assistant Director of Nursing (ADON) | Reported abuse incident on 7/20/24 and communicated with DON and NHA | |
| Nursing Home Administrator (NHA) | Provided facility policies and interviewed regarding abuse investigations | |
| Social Services Director (SSD) | Interviewed regarding Resident #1's triggers and family communication |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide safe and appropriate respiratory care and services per physician orders for four residents.
Complaint Details
The complaint investigation found substantiated issues with respiratory care including lack of physician orders for oxygen administration, inconsistent monitoring of oxygen saturation, and incorrect oxygen flow rates being administered.
Findings
The facility failed to ensure physician's orders for oxygen were obtained prior to administration for some residents, oxygen saturation levels were not consistently monitored, and residents did not always receive the correct oxygen flow rate as ordered by physicians.
Deficiencies (1)
F 0695: The facility failed to obtain physician's orders for oxygen prior to administration for Residents #2 and #10. Oxygen saturation levels (SpO2) were not consistently monitored for Residents #2, #10, and #12. Resident #12's physician's order did not accurately specify the correct oxygen flow rate. Resident #13 received oxygen at a higher flow rate than ordered.
Report Facts
Residents reviewed for respiratory care: 13
Residents with respiratory care deficiencies: 4
Oxygen flow rate for Resident #2: 3
Oxygen flow rate for Resident #10: 4
Oxygen flow rate for Resident #12: 3
Oxygen flow rate for Resident #13: 4.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding oxygen administration policies and issues with physician orders | |
| Licensed Practical Nurse (LPN) #2 | Interviewed and identified oxygen flow rates and issues with physician orders for Residents #10 and #13 | |
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding oxygen administration and SpO2 checks for Resident #12 |
Inspection Report
Routine
Deficiencies: 4
Date: Mar 14, 2024
Visit Reason
The inspection was conducted to evaluate the facility's compliance with respiratory care requirements and to ensure residents received necessary respiratory care and services per physician orders.
Findings
The facility failed to ensure physician's orders for oxygen were obtained prior to administration for some residents, oxygen saturation levels were not consistently monitored, and oxygen flow rates were not always provided according to physician orders for four residents reviewed.
Deficiencies (4)
Failed to obtain physician's orders for oxygen prior to administration for Resident #2 and Resident #10.
Failed to consistently monitor oxygen saturation levels (SpO2) for Resident #2, Resident #10, and Resident #12.
Resident #12's physician's order for oxygen did not accurately identify the correct oxygen flow rate.
Staff provided incorrect oxygen flow rate per physician's order to Resident #13 (4.5 LPM administered instead of 2 LPM ordered).
Report Facts
Oxygen flow rate: 3
Oxygen flow rate: 4
Oxygen flow rate: 3
Oxygen flow rate: 4.5
SpO2 measurement: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding oxygen administration policies and issues with physician orders. | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about oxygen flow rates and physician orders for Residents #10 and #13. | |
| Licensed Practical Nurse (LPN) #1 | Interviewed about oxygen administration and SpO2 checks for Resident #12. |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 29, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify residents or their responsible parties about medication changes and room/roommate changes, and failure to revise care plans to address resident behaviors that placed others at risk.
Complaint Details
The complaint investigation substantiated failures in notification to responsible parties about medication and room changes, and failure to update care plans to prevent resident-to-resident harm. Resident #3 sustained facial trauma and brain hemorrhages after an altercation with Resident #1.
Findings
The facility failed to notify the responsible party of a psychotropic medication order for Resident #2, failed to provide timely written notification of room and roommate changes for Residents #1 and #3, and failed to revise the care plan for Resident #1 to address behaviors that led to harm to Resident #3. Resident #3 suffered serious injuries from a resident-to-resident altercation.
Deficiencies (3)
F 0552: The facility failed to notify Resident #2's responsible party of a psychotropic medication order and did not obtain a signed consent form.
F 0559: The facility failed to provide timely written or verbal notification of room and roommate changes to Residents #1 and #3 or their representatives.
F 0657: The facility failed to revise Resident #1's care plan to reflect behaviors that placed Resident #3 and others at risk, resulting in a resident-to-resident altercation causing serious injury.
Report Facts
Residents reviewed for notification: 13
Residents reviewed for notification: 3
Residents affected: 1
Residents affected: 2
Date of medication order: Oct 23, 2023
Date of room change: Oct 12, 2023
Date of incident: Oct 13, 2023
Date of behavior care plan: Jan 20, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses (DON) | Interviewed regarding responsibility for notification and consent for medication changes | |
| Charge Nurse (CN) | Interviewed regarding notification responsibilities and incident response | |
| Social Services Director (SSD) | Interviewed regarding notification and care plan review | |
| Nursing Home Administrator (NHA) | Interviewed regarding incident investigation and facility response | |
| CNA #1 | Certified Nurse Aide | Provided written statement about resident-to-resident altercation |
| RN #1 | Registered Nurse | Provided written statement about resident-to-resident altercation |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Nov 29, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to notify responsible parties of medication changes, failure to provide written notification of room and roommate changes, and failure to revise care plans to address resident behaviors that placed others at risk.
Complaint Details
The complaint investigation substantiated failures in notification and care planning that contributed to a resident-to-resident altercation causing serious injury to Resident #3. The investigation included interviews with the director of nurses, charge nurse, social services director, nursing home administrator, and review of medical records and facility policies.
Findings
The facility failed to notify the responsible party of a psychotropic medication order for Resident #2, failed to provide timely written notification of room and roommate changes for Residents #1 and #3, and failed to revise the care plan for Resident #1 to reflect behaviors that led to harm to Resident #3. Resident #3 suffered serious injuries from a resident-to-resident altercation involving Resident #1.
Deficiencies (3)
Failed to notify the responsible party when a psychotropic medication was ordered and administered for Resident #2.
Failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #3 and Resident #1 and/or their representatives.
Failed to revise the care plan for Resident #1 to reflect, respond, and alert staff to behaviors that placed Resident #3 and others at risk for harm, resulting in actual harm.
Report Facts
Residents reviewed: 13
Residents affected: 3
Medication dosage: 2
Dates of incidents: Roommate change and altercation occurred on 10/12/23 and 10/13/23
BIMS scores: Resident #2 had severe cognitive impairment with BIMS score 99/15 (likely a typographical error), Resident #3 had moderate cognitive deficit with BIMS 6/15, Resident #1 had severe cognitive impairment with BIMS 99/15 (likely a typographical error)
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nurses | Director of Nurses (DON) | Interviewed regarding notification responsibilities and documentation |
| Charge Nurse | Charge Nurse (CN) | Interviewed regarding notification responsibilities and incident response |
| Social Services Director | Social Services Director (SSD) | Interviewed regarding notification and care plan review |
| Nursing Home Administrator | Nursing Home Administrator (NHA) | Interviewed regarding resident-to-resident altercation and facility response |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Provided written statement about resident-to-resident altercation |
| Registered Nurse #1 | Registered Nurse (RN) | Provided written statement about resident-to-resident altercation |
Inspection Report
Re-Inspection
Census: 70
Deficiencies: 21
Date: Sep 5, 2023
Visit Reason
Re-inspection survey to follow up on previously cited deficiencies and verify correction of issues related to medication self-administration, resident rights, abuse prevention, financial management, nutrition, activities, infection control, medication administration, facility assessment, and quality assurance.
Findings
The facility was found deficient in multiple areas including failure to ensure clinical appropriateness of medication self-administration, inadequate response to resident grievances, failure to manage resident funds properly, failure to prevent resident abuse and altercations, improper medication storage and administration, inadequate activities programming, failure to prevent pressure injuries, failure to prevent falls and provide appropriate care, failure to follow menus and provide adequate nutrition, failure to maintain infection control practices, and failure to maintain an effective quality assurance program.
Deficiencies (21)
F554: Facility failed to ensure clinical appropriateness of medication self-administration and secure storage for Resident #13's medications.
F565: Facility failed to ensure prompt action on grievances related to food committee concerns.
F567: Facility failed to manage personal funds accounts adequately for seven residents, including failure to assist with bank accounts and spend down notifications.
F600: Facility failed to protect residents from abuse, including substantiated physical abuse between Residents #56 and #188 and resident-to-resident altercations involving Residents #64 and #52.
F658: Facility failed to follow professional standards by storing medications in medication cups in medication carts.
F676: Facility failed to provide communication tools and support for Resident #63 with language barriers.
F679: Facility failed to provide adequate activities and socialization for Residents #21 and #335, including lack of comprehensive care plans and insufficient activity staffing.
F686: Facility failed to provide appropriate pressure ulcer care and timely treatment for Residents #335 and #1.
F688: Facility failed to provide contracture management services for Resident #62.
F689: Facility failed to provide a safe environment free from accident hazards, including failure to identify elopement risk and implement wander guards for multiple residents and failure to implement timely fall interventions.
F692: Facility failed to provide adequate nutrition to multiple residents, including failure to monitor weight loss, provide nutritional interventions, and follow diet orders.
F712: Facility failed to ensure timely physician visits for Residents #297 and #295 within required timeframes after admission.
F744: Facility failed to provide person-centered dementia care for Residents #64, #52, and #116, including failure to address behavioral symptoms and provide meaningful activities.
F759: Facility medication administration error rate was 32%, with 18 errors out of 56 opportunities observed.
F761: Facility failed to properly label and date insulin pens and vials and improperly stored medications and vaccines with resident food.
F803: Facility failed to follow menus, including serving incorrect portion sizes and substituting menu items without notification, resulting in inadequate nutrition for residents.
F812: Facility failed to store, prepare, distribute, and serve food in a sanitary manner, including failure to label and date food, clean kitchen and nourishment rooms, cover garbage, perform hand hygiene during meal assistance, monitor refrigerator temperatures, monitor dishwasher temperature, timely put away food deliveries, and properly cool cooked food.
F838: Facility failed to conduct a comprehensive facility assessment including staff competencies, training, and facility risk assessments to ensure competent care during day-to-day operations and emergencies.
F867: Facility failed to implement an effective QAPI program to identify and address quality deficiencies and ensure systemic improvement.
F880: Facility failed to maintain infection control practices, including failure to perform hand hygiene during medication administration.
F881: Facility failed to implement an antibiotic stewardship program that included monitoring and evaluation of prophylactic antibiotic use for multiple residents.
Report Facts
Residents in sample: 70
Medication administration errors: 18
Medication administration error rate: 32
Weight loss Resident #111: 20.2
Weight loss Resident #116: 34.8
Weight loss Resident #26: 24.6
Weight loss Resident #87: 11.4
Weight loss Resident #31: 5
Weight loss Resident #116: 20.4
Weight loss Resident #111: 20.2
Weight loss Resident #26: 11.51
Weight loss Resident #116: 23.14
Weight loss Resident #116: 34.8
Weight loss Resident #116: 115.6
Weight loss Resident #111: 147
Weight loss Resident #87: 201.4
Weight loss Resident #31: 116
Weight loss Resident #14: 130.6
Weight loss Resident #14: 133
Weight loss Resident #14: 135.6
Weight loss Resident #14: 140
Weight loss Resident #14: 144.2
Weight loss Resident #14: 148.2
Weight loss Resident #14: 150.4
Weight loss Resident #116: 115.6
Weight loss Resident #116: 150.8
Weight loss Resident #116: 167.2
Weight loss Resident #116: 148.2
Weight loss Resident #116: 130.6
Weight loss Resident #116: 132.8
Weight loss Resident #116: 144.2
Weight loss Resident #116: 140
Weight loss Resident #116: 135.6
Weight loss Resident #116: 115.6
Weight loss Resident #116: 150.4
Weight loss Resident #116: 148.2
Weight loss Resident #116: 144.2
Weight loss Resident #116: 140
Weight loss Resident #116: 135.6
Weight loss Resident #116: 115.6
Inspection Report
Routine
Deficiencies: 1
Date: Sep 5, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with nutritional care requirements and to evaluate the care provided to residents at nutritional risk, including monitoring weight loss and ensuring appropriate nutritional interventions.
Findings
The facility failed to implement adequate nutritional interventions for multiple residents experiencing significant or severe weight loss. The kitchen staff did not consistently provide double portions or fortified foods as ordered by the registered dietitian. Several residents had documented weight loss without appropriate corrective actions, and nutritional supplements were sometimes expired or not administered as prescribed.
Deficiencies (1)
F 0692: The facility failed to provide enough food and fluids to maintain residents' health, resulting in significant and severe weight loss for multiple residents. Nutritional interventions such as double portions and fortified foods were not consistently provided as ordered.
Report Facts
Weight loss: 20.2
Weight loss: 24.6
Weight loss: 34.8
Weight loss: 11.2
Weight loss: 16.4
Weight loss: 12.3
Weight loss: 6.6
Weight loss: 11.51
Weight loss: 23.14
Weight loss: 13
Weight loss: 17
Weight loss: 5
Weight loss: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Interviewed regarding Resident #111 and Resident #87 nutritional care and weight loss. |
| Certified Nurse Aide #8 | CNA | Interviewed regarding Resident #111 and Resident #87 meal intake and behaviors. |
| Registered Dietitian | RD | Interviewed regarding nutritional assessments, interventions, and challenges with kitchen staff compliance. |
| Director of Nursing | DON | Interviewed regarding monitoring of resident weights and nutritional interventions. |
| Kitchen Manager | Kitchen Manager | Interviewed regarding staff compliance with RD recommendations and nutritional interventions. |
| Registered Nurse #7 | RN | Interviewed regarding Resident #87 nutritional supplement orders. |
Inspection Report
Annual Inspection
Deficiencies: 19
Date: Sep 5, 2023
Visit Reason
The inspection was conducted as part of the annual recertification survey of Pikes Peak Post Acute nursing home to assess compliance with federal regulations regarding resident care, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, grievance follow-up, personal funds management, abuse prevention, medication storage and administration, communication tools for non-English speaking residents, activity programming, pressure injury care, contracture management, accident hazard prevention, nutritional care and menu adherence, physician visit timeliness, dementia care, medication error rates, medication labeling and storage, food safety and sanitation, facility-wide resource assessment, quality assurance program effectiveness, infection control, and antibiotic stewardship.
Deficiencies (19)
Failed to ensure Resident #13 was assessed for clinical appropriateness of self-administration of medication and medications left at bedside were secured.
Failed to follow up with residents' concerns regarding meals brought up by the food committee.
Failed to ensure personal funds accounts were managed adequately for seven residents.
Failed to ensure three residents were kept free from abuse including physical abuse and resident to resident altercations.
Failed to ensure medications were not dispensed and stored in medication cups in the top drawer of the medication cart.
Failed to provide language communication tools for Resident #63 to effectively communicate needs and participate in social conversation.
Failed to provide activities designed to support residents' physical, mental and psychosocial well-being for Residents #21 and #335.
Failed to provide necessary treatment and services to treat and prevent pressure injuries for Residents #1 and #335.
Failed to provide services or treatments to prevent reduction in range of motion for Resident #62.
Failed to provide an environment free from accident hazards and adequate supervision to prevent accidents for eight residents.
Failed to ensure medication error rate was below 5%, with an observed error rate of 32%.
Failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, including insulin dating and separation from food.
Failed to ensure menus were followed to meet residents' nutritional needs including correct portion sizes and correct items served.
Failed to provide food that accommodated resident allergies and preferences for Residents #118 and #14.
Failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen, serving kitchens, and nourishment rooms.
Failed to conduct and document a comprehensive facility-wide assessment including staff competencies, training, and facility-based risk assessments.
Failed to implement an effective quality assurance program to identify and address facility compliance concerns and prevent repeat deficiencies.
Failed to maintain an infection control program designed to prevent the spread of infection, including failure to perform appropriate hand hygiene during medication administration.
Failed to ensure antibiotic stewardship program included protocols for documentation and monitoring of prophylactic antibiotic use for five residents.
Report Facts
Medication administration error rate: 32
Weight loss: 34.8
Weight loss: 24.6
Weight loss: 20.2
Weight loss: 11.4
Weight loss: 16.4
Weight loss: 12.3
Weight loss: 6.6
Weight loss: 17.6
Weight loss: 13.16
Weight loss: 10.24
Weight loss: 6.91
Weight loss: 4.12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in medication administration and hand hygiene deficiencies |
| RN #4 | Registered Nurse | Witnessed resident to resident altercation and provided observations on dementia care |
| RN #2 | Registered Nurse | Observed and treated pressure injuries on residents |
| Director of Nursing | Director of Nursing | Interviewed regarding multiple deficiencies including medication administration, infection control, and dementia care |
| Dietary Manager | Dietary Manager | Interviewed regarding food service deficiencies and menu adherence |
| Registered Dietitian | Registered Dietitian | Interviewed regarding nutritional care and interventions |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed regarding facility assessment, quality assurance, and overall facility operations |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control program and hand hygiene |
Inspection Report
Routine
Deficiencies: 6
Date: Sep 5, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with nutritional care requirements and to evaluate the care provided to residents at nutritional risk, including monitoring weight loss and ensuring appropriate nutritional interventions.
Findings
The facility failed to provide adequate nutritional care to several residents, including failure to implement nutritional interventions to prevent or address significant and severe weight loss. The kitchen staff did not consistently follow dietitian recommendations for double portions or fortified foods, and weights were not obtained as ordered. Multiple residents experienced significant or severe weight loss without appropriate interventions.
Deficiencies (6)
Failure to provide large or double portions as ordered for Resident #111, resulting in weight loss.
Failure to obtain weights weekly as ordered for Resident #111.
Failure to implement nutritional interventions to address gradual and severe weight loss for Resident #87.
Failure to provide nutritional interventions to address severe weight loss for Resident #26, including failure to accommodate dietary restrictions.
Failure to provide adequate nutritional care and interventions for Resident #116, resulting in severe weight loss.
Failure to implement nutritional interventions for Resident #31 at nutritional risk due to poor oral intake and other conditions.
Report Facts
Weight loss: 6.6
Weight loss: 12.3
Weight loss: 16.4
Weight loss: 20.2
Weight loss: 11.2
Weight loss: 24.6
Weight loss: 34.8
Weight loss: 20.4
Weight loss: 17
Weight loss: 13
Weight loss: 5
Weight loss: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #3 | LPN | Interviewed regarding Resident #111 and Resident #87 nutritional care and observations |
| Certified Nurse Aide #8 | CNA | Interviewed regarding Resident #111 and Resident #87 meal intake and behaviors |
| Registered Dietitian | RD | Interviewed regarding nutritional assessments, interventions, and challenges with kitchen staff compliance |
| Director of Nursing | DON | Interviewed regarding weight monitoring responsibilities and expired supplements |
| Kitchen Manager | Interviewed regarding kitchen staff compliance with RD recommendations | |
| Registered Nurse #7 | RN | Interviewed regarding Resident #87 nutritional supplements |
Inspection Report
Routine
Deficiencies: 7
Date: Jun 10, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements including PASARR screening, care planning, treatment and care, accident prevention, catheter use, infection control, and environmental safety at Pikes Peak Post Acute nursing home.
Findings
The facility was found deficient in multiple areas including delayed PASARR Level I screening, failure to revise care plans for residents with oxygen and catheter needs, inadequate skin integrity monitoring, unsafe hot water temperatures, failure to justify indwelling urinary catheter use, incomplete smoking assessments, and lapses in infection control practices including improper PPE use and lack of isolation signage.
Deficiencies (7)
Failure to ensure PASARR Level I screening was completed within 30 days of admission for one resident.
Failure to develop and revise care plans within 7 days for residents with respiratory and catheter care needs.
Failure to identify and treat skin breakdown for one resident with open cracks in skin.
Failure to maintain safe hot water temperatures between 105-115 degrees Fahrenheit in secured memory care unit.
Failure to ensure indwelling urinary catheter was used with adequate justification and proper physician orders.
Failure to complete smoking assessment prior to allowing resident to smoke.
Failure to maintain effective infection prevention and control program including improper PPE use and lack of isolation signage.
Report Facts
Deficiencies cited: 7
Hot water temperature: 121.8
Hot water temperature: 128.4
Hot water temperature: 116.7
Skin wound size: 1
Skin wound size: 5
Skin wound size: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Worker #1 | Social Worker | Interviewed regarding PASARR screening delays |
| Director of Nursing | Director of Nursing | Interviewed regarding PASARR process and care plan expectations |
| Administrator | Administrator | Interviewed regarding PASARR waiver and smoking assessments |
| Registered Nurse #3 | Registered Nurse | Interviewed regarding care plan reviews |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Interviewed regarding oxygen setting monitoring and care planning |
| Certified Nursing Assistant #5 | Certified Nursing Assistant | Interviewed regarding resident oxygen setting changes |
| Licensed Practical Nurse #7 | Licensed Practical Nurse | Interviewed regarding skin assessments |
| Certified Nursing Assistant #3 | Certified Nursing Assistant | Interviewed regarding skin breakdown observations |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Interviewed regarding skin assessment documentation |
| Nurse Practitioner #1 | Nurse Practitioner | Interviewed regarding skin wound evaluation |
| Maintenance Staff #1 | Maintenance Staff | Interviewed regarding hot water temperature monitoring |
| Maintenance Staff #2 | Maintenance Staff | Interviewed regarding hot water temperature calibration and adjustments |
| Certified Nursing Assistant #1 | Certified Nursing Assistant | Interviewed regarding urinary catheter awareness |
| Registered Nurse #5 | Registered Nurse | Interviewed regarding urinary catheter orders and placement |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Interviewed regarding smoking assessment |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Interviewed regarding isolation procedures |
| Certified Nursing Assistant #2 | Certified Nursing Assistant | Interviewed regarding PPE use and isolation signage |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding resident COVID-19 status and isolation |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control program and PPE use |
| Administrator | Administrator | Interviewed regarding infection control policies and staff expectations |
Inspection Report
Routine
Deficiencies: 6
Date: Jun 10, 2022
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements including PASARR screening, care planning, skin integrity management, smoking assessments, water temperature safety, catheter use, and infection control.
Findings
The facility failed to complete timely PASARR Level I screening for one resident, did not revise care plans for residents with oxygen and catheter needs, failed to identify and treat skin breakdown, did not complete smoking assessments prior to allowing smoking, maintained unsafe hot water temperatures on one hall, used an indwelling urinary catheter without adequate justification, and failed to maintain effective infection control precautions for residents with COVID-19.
Deficiencies (6)
F0645: The facility failed to ensure PASARR Level I screening was completed within 30 days of admission for one resident.
F0657: The facility failed to revise care plans for one resident with an indwelling urinary catheter and one resident with changes in oxygen administration settings.
F0684: The facility failed to provide appropriate treatment and care for one resident with skin integrity issues, missing identification and documentation of an open skin area.
F0689: The facility failed to maintain safe hot water temperatures between 105 and 115 degrees Fahrenheit on one hall and failed to complete a smoking assessment for one resident prior to smoking.
F0690: The facility failed to ensure an indwelling urinary catheter was used with adequate justification for one resident.
F0880: The facility failed to maintain an infection control program to prevent transmission of communicable diseases, including failure to wear appropriate PPE and lack of isolation signage for residents with COVID-19.
Report Facts
Date of survey completion: Jun 10, 2022
PASARR screening delay: 4
Oxygen order: 4
Skin wound size: 1
Skin wound redness size: 5
Skin wound redness width: 4
Hot water temperature: 121.8
Hot water temperature: 128.4
Hot water temperature: 136
Hot water temperature: 143
Hot water temperature: 146
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Registered Nurse | Reviewed care plans and reported changes related to oxygen settings |
| LPN #8 | Licensed Practical Nurse | Checked oxygen concentrators and discussed resident oxygen setting changes |
| CNA #5 | Certified Nursing Assistant | Reported resident changing oxygen settings |
| DON | Director of Nursing | Provided expectations on care planning and oxygen management |
| Administrator | Discussed PASARR waiver and smoking assessment expectations | |
| LPN #5 | Licensed Practical Nurse | Conducted smoking assessment after incident involving Resident #260 |
| RN #5 | Registered Nurse | Entered physician order for indwelling urinary catheter and discussed catheter use |
| CNA #2 | Certified Nursing Assistant | Observed not wearing PPE entering isolation rooms |
| LPN #6 | Licensed Practical Nurse | Discussed isolation procedures and resident care |
| RN #1 | Registered Nurse | Discussed resident COVID-19 status and quarantine |
| NP #1 | Nurse Practitioner | Examined resident's skin wound and provided assessment |
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