01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-01-30 | 12 | 2025-01-30 | 1 |
| Cycle 2 | 2023-09-05 | 25 | 2023-09-05 | 0 |
| Cycle 3 | 2022-06-10 | 10 | 2022-06-10 | 0 |
CMS CCN 0654152026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Pikes Peak Post Acute
2719 N Union Blvd · Colorado Springs, CO 80909 · El Paso County
Certified beds210CMS provider file
Recent citation rows48current CMS citation release
Penalty rows4current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
48 rows in the current release
3 rows carry G–L scope/severity codes; 0 carry J–L. 5 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-11-20 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-12-19 · complaint2025-11-20 · HEALTHF0744Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Correction field: Deficient, Provider has date of correction · 2025-12-19 · complaint2025-01-30 · FIREE0015Severity F · widespread; potential for more than minimal harm
Emergency Preparedness Deficiencies
Address subsistence needs for staff and patients.
Correction field: Deficient, Provider has date of correction · 2025-02-182025-01-30 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2025-02-182025-01-30 · HEALTHF0561Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Correction field: Deficient, Provider has date of correction · 2025-02-182025-01-30 · HEALTHF0585Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-02-182025-01-30 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-02-182025-01-30 · HEALTHF0677Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-02-182025-01-30 · HEALTHF0685Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
Correction field: Deficient, Provider has date of correction · 2025-02-182025-01-30 · HEALTHF0689Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-02-182025-01-30 · HEALTHF0730Severity E · pattern; potential for more than minimal harm
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Correction field: Deficient, Provider has date of correction · 2025-02-182025-01-30 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-02-18 · complaint2025-01-30 · HEALTHF0921Severity D · isolated; potential for more than minimal harm
Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Correction field: Deficient, Provider has date of correction · 2025-02-182024-09-17 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2024-09-18 · complaint2024-09-17 · HEALTHF0609Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Correction field: Deficient, Provider has date of correction · 2024-11-13 · complaint2024-09-17 · HEALTHF0610Severity E · pattern; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
Correction field: Deficient, Provider has date of correction · 2024-11-13 · complaint2024-03-14 · HEALTHF0695Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2024-04-12 · complaint2023-11-29 · HEALTHF0552Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
Correction field: Deficient, Provider has date of correction · 2023-11-30 · complaint2023-11-29 · HEALTHF0559Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.
Correction field: Deficient, Provider has date of correction · 2023-11-30 · complaint2023-11-29 · HEALTHF0657Severity G · isolated actual harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2023-11-30 · complaint2023-09-05 · HEALTHF0554Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
Correction field: Deficient, Provider has date of correction · 2023-09-272023-09-05 · HEALTHF0565Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
Correction field: Deficient, Provider has date of correction · 2023-11-152023-09-05 · HEALTHF0567Severity E · pattern; potential for more than minimal harm
Resident Rights Deficiencies
Honor the resident's right to manage his or her financial affairs.
Correction field: Deficient, Provider has date of correction · 2023-09-272023-09-05 · HEALTHF0600Severity D · isolated; potential for more than minimal harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2023-11-0503 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2024-09-17 | Fine | $39,917 | 0 |
| 2024-09-17 | Payment Denial | $0 | 28 |
| 2023-09-05 | Fine | $49,401 | 0 |
| 2023-09-05 | Payment Denial | $0 | 63 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- PANTHER MASTER TENANT, LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 09/01/2023
- PROVIDENCE GROUP NH, LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST100% · since 09/01/2023
- SHEPHERD, DAVIDIndividual · CONTRACTED MANAGING EMPLOYEENOT APPLICABLE · since 01/01/2022
- CREASON, JONATHANIndividual · W-2 MANAGING EMPLOYEENOT APPLICABLE · since 09/01/2023
- APT, FREDERICKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2024
- HANCOCK, MARKIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2024
- JERGENSEN, JOSHUAIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2024
- MITCHELL, JOHNIndividual · CORPORATE OFFICERNOT APPLICABLE · since 01/01/2024
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.61per resident day
RN hours0.61per resident day
Weekend nurse hours3.30per resident day
Staff turnover60.9%CMS reported field
06 / LOCAL RECORDS
Open the Colorado Springs ledger →Other published facilities nearby
Advanced Health Care Of Colorado Springs34 beds · CMS overall 5/531 citation rowsBear Creek Senior Living45 beds · CMS overall 4/526 citation rowsBrookdale Skyline82 beds · CMS overall 5/546 citation rowsCenter At Centennial, The80 beds · CMS overall 5/537 citation rowsColonial Rehabilitation And Nursing, Llc80 beds · CMS overall 1/553 citation rowsFalcon Heights Rehabilitation And Nursing Llc107 beds · CMS overall 2/562 citation rowsFountain View Rehabilitation And Nursing Llc90 beds · CMS overall 3/525 citation rowsGardens, The45 beds · CMS overall 5/521 citation rows