Complaint Investigation

Pikes Peak Post Acute

November 20, 2025 · Colorado Springs, CO · 2719 N Union Blvd

Citations 2

CMS Rating 1/5

Beds 210

Provider ID 065415

Healthcare Facility

Pikes Peak Post Acute

Colorado Springs, CO · View full profile →

Source Document

Official CMS Inspection Report (Medicare.gov)

Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.

Inspection Summary

PIKES PEAK POST ACUTE in COLORADO SPRINGS, CO — inspection on November 20, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0600

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Potential for More Than Minimal Harm

another resident's room, she would provide redirection.

She said she did not know where written interventions were documented for each resident.

She said she had worked at the facility for two years and felt she knew each resident well enough to know what interventions worked.

She said all allegations or incidents of abuse were reported to the abuse coordinator.

CNA #1 said prior to one-to-one supervision, Resident #4 wandered freely throughout the unit, going in and out of other residents' rooms.

She said that if a room door was open, Resident #4 would go inside.

She said some days, Resident #4 was able to be redirected and other times she could not be redirected at all.

She said the one-to-one supervision began after the incident on 10/31/25 with Resident #5 and continued for at least two weeks before she was discharged to another facility.

She said she believed the lack of staffing directly contributed to the incident between Residents #4 and #5.

CNA #1 said when she came on shift on 10/31/25, she was informed Resident #4 had entered Resident #5's room and hit her.

She said Resid

Facility ID:

IDENTIFICATION NUMBER:

Building

COMPLETED

11/20/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Pikes Peak Post Acute

2719 N Union Blvd Colorado Springs, CO 80909

SUMMARY STATEMENT OF DEFICIENCIES

FF0744

Quality of Life and Care Deficiencies

Potential for More Than Minimal Harm

Resident #3 in her room and closing the door as an intervention for her wandering.

The AD was interviewed on 11/20/25 at 4:16 p.m.

The AD said she did a four hour dementia training when people were hired, annually, and then as needed.

She said she also did on-the-spot training with staff on the secured unit.

She said for Resident #3, there was a busy box for her but it would disappear.

She said Resident #3's daughter would bring in snacks and there was a stash of her favorite snacks for staff to offer her.

She said regular staff members were aware of Resident #3's interventions.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?

F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.

Were these violations corrected?

Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.

How often do nursing home inspections happen?

CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.

What should families do about these violations?

Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in COLORADO SPRINGS, CO, (5) Report new concerns to state authorities.

Where can I see the full inspection report?

Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from PIKES PEAK POST ACUTE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.

More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.