Pikes Peak Post Acute
2719 N Union Blvd, Colorado Springs, CO 80909 · El Paso County · 210 certified beds · avg 168 residents/day · certified since Sep 9, 2015
Abuse citation flag (CMS)
Part of chain: PACS GROUP (274 facilities, chain avg rating 2.9★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
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)
▲ Actual harm, one-off · Sep 17, 2024 · 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 (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Sep 18, 2024 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Nov 29, 2023 · F-0657 · triggered by a complaint
The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required.
Why it matters: Delays or gaps in care planning mean staff may work without a clear, current roadmap for the resident's daily care and treatment.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Nov 30, 2023 (Deficient, Provider has date of correction)
▲ Actual harm, repeated · Sep 5, 2023 · F-0692 · triggered by a complaint
The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.
Severity (H): Multiple residents were actually harmed by the same failure — a pattern of real harm, not an isolated incident.
Corrected: Nov 7, 2023 (Deficient, Provider has date of correction)
All citations in the current public record (47)
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 |
|---|---|---|
| Nov 20, 2025 | D · Potential for harm, one-off | 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 20, 2025 | D · Potential for harm, one-off | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. · from a complaint |
| Jan 30, 2025 | E · Potential for harm, repeated | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. |
| Jan 30, 2025 | E · Potential for harm, repeated | The facility did not observe each nurse aide's job performance or provide regular training as required. |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. |
| Jan 30, 2025 | D · Potential for harm, one-off | 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. |
| Jan 30, 2025 | D · Potential for harm, one-off | 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. |
| Jan 30, 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. |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not help a resident get vision and hearing services — such as eye exams, glasses, hearing tests, or hearing aids. |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jan 30, 2025 | D · Potential for harm, one-off | 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. · from a complaint |
| Jan 30, 2025 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Sep 17, 2024 | ▲ G · Actual harm, one-off | 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 |
| Sep 17, 2024 | 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. · from a complaint |
| Sep 17, 2024 | 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 |
| Mar 14, 2024 | E · Potential for harm, repeated | 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. · from a complaint |
| Nov 29, 2023 | ▲ G · Actual harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint |
| Nov 29, 2023 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. · from a complaint |
| Nov 29, 2023 | D · Potential for harm, one-off | The facility did not honor residents' right to share a room with their spouse or a roommate of their choosing, or moved residents to a different room without written notice beforehand. · from a complaint |
| Sep 5, 2023 | ▲ H · Actual harm, repeated | The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration. · from a complaint |
| Sep 5, 2023 | F · Potential for harm, facility-wide | The facility's menus did not meet residents' nutritional needs, or were not prepared in advance, followed as written, kept up to date, or reviewed by a dietician. |
| Sep 5, 2023 | 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. |
| Sep 5, 2023 | F · Potential for harm, facility-wide | The facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies. |
| Sep 5, 2023 | F · Potential for harm, facility-wide | The facility did not run an ongoing quality assurance committee that reviews care problems and creates plans to fix them. |
| Sep 5, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to form and take part in resident or family groups, such as a resident council. |
| Sep 5, 2023 | E · Potential for harm, repeated | The facility did not honor residents' right to manage their own money and financial affairs. |
| Sep 5, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Sep 5, 2023 | E · Potential for harm, repeated | The facility did not provide the right treatment and services for residents with dementia or signs of dementia. Dementia care requires specific approaches, training, and patience. |
| Sep 5, 2023 | E · Potential for harm, repeated | 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. |
| Sep 5, 2023 | 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. |
| Sep 5, 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. |
| Sep 5, 2023 | E · Potential for harm, repeated | The facility did not have a working program to monitor how antibiotics are used. Tracking antibiotic use helps make sure these drugs are given only when needed and remain effective. |
| Sep 5, 2023 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. |
| Sep 5, 2023 | D · Potential for harm, one-off | 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. |
| Sep 5, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Sep 5, 2023 | D · Potential for harm, one-off | The facility allowed residents to lose the ability to do daily activities — like bathing, dressing, and eating — when there was no medical reason for the decline. Good care helps residents keep the abilities they have. |
| Sep 5, 2023 | 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. |
| Sep 5, 2023 | D · Potential for harm, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. |
| Sep 5, 2023 | D · Potential for harm, one-off | The facility did not provide the care needed to maintain or improve residents' movement and flexibility — such as range-of-motion exercises — leading to avoidable decline. |
| Sep 5, 2023 | D · Potential for harm, one-off | The facility did not make sure residents actually saw their doctor face-to-face at all required visits. Doctors must examine nursing home residents in person on a regular schedule. |
| Sep 5, 2023 | D · Potential for harm, one-off | The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives. |
| Jun 10, 2022 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jun 10, 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. |
| Jun 10, 2022 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Jun 10, 2022 | D · Potential for harm, one-off | 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. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (22 → 10).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2022 | 6 | 0 | E |
| 2023 | 25 | 2 | H ▲ |
| 2024 | 4 | 1 | G ▲ |
| 2025 | 12 | 0 | E |
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)
2 fines totaling $89,318, plus 2 Medicare payment denial periods.
| Date | Type | Amount / length |
|---|---|---|
| Sep 17, 2024 | Fine | $39,917 |
| Sep 17, 2024 | Payment Denial | 28 days from Oct 16, 2024 |
| Sep 5, 2023 | Fine | $49,401 |
| Sep 5, 2023 | Payment Denial | 63 days from Sep 28, 2023 |
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) | 3.79 | 3.89 | 3.95 | top 46% in Colorado; top 49% in the U.S. |
| Registered Nurse hours | 0.64 | 0.86 | 0.69 | bottom 30% in Colorado; top 43% in the U.S. |
| Weekend total nurse staffing | 3.46 | 3.44 | 3.50 | top 38% in Colorado; top 44% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.40 | 0.61 | 0.48 | bottom 24% in Colorado; top 48% in the U.S. |
| Total nursing staff turnover (%) | 60.9 | 47.1 | 45.8 | bottom 15% in Colorado; bottom 15% in the U.S. |
| RN turnover (%) | 44.8 | 44.6 | 42.9 | bottom 48% in Colorado; bottom 44% 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 3.61, RN 0.61, weekend 3.30. Staffing rating: 3/5.
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: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Panther Master Tenant, LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 09/01/2023 |
| Providence Group NH, LLC | Organization | 5% or Greater Indirect Ownership Interest | 100% | 09/01/2023 |
| Apt, Frederick | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Creason, Jonathan | Individual | W-2 Managing Employee | NOT APPLICABLE | 09/01/2023 |
| Hancock, Mark | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Jergensen, Joshua | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Mitchell, John | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2024 |
| Shepherd, David | Individual | Contracted Managing Employee | NOT APPLICABLE | 01/01/2022 |
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?"
- "Who is on the team that builds each resident's care plan, and how quickly is it in place after admission?"
- "How do you monitor residents' weight and eating, and what happens when someone starts losing weight?"
- "What specific dementia training do your staff receive, and how do you handle difficult moments without medication?"
- "Walk me through what happens when a resident or family files a grievance — who responds and how fast?"
- "How often do you evaluate your nurse aides and what ongoing training do they receive?"
- "Can you give me examples of how you adjust daily routines and room setups to fit each resident's preferences?"
- "What choices do residents have over their daily schedule, like meal times, bathing, and activities?"
- "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 |
|---|---|---|---|---|---|
| Colonial Rehabilitation and Nursing, LLC | 0.6 mi | Colorado Springs, CO | ★☆☆☆☆ | 2/5 | abuse |
| Sunny Vista Living Center | 1.8 mi | Colorado Springs, CO | ★★★☆☆ | 3/5 | |
| Springs Village Care Center | 2.2 mi | Colorado Springs, CO | ★★☆☆☆ | 2/5 | |
| Medallion Post Acute Rehabilitation | 2.4 mi | Colorado Springs, CO | ★☆☆☆☆ | 1/5 | |
| Advanced Health Care of Colorado Springs | 2.8 mi | Colorado Springs, CO | ★★★★★ | 5/5 | |
| Life Care Center of Colorado Springs | 2.9 mi | Colorado Springs, CO | ★★★★★ | 4/5 | |
| The Healthcare Resort of Colorado Springs | 3.2 mi | Colorado Springs, CO | ★★★☆☆ | 2/5 | |
| Center at Centennial, the | 3.4 mi | Colorado Springs, CO | ★★★★★ | 4/5 | |
| Kiowa Hills Rehabilitation and Nursing, LLC | 3.5 mi | Colorado Springs, CO | ★☆☆☆☆ | 1/5 | |
| Fountain View Rehabilitation and Nursing LLC | 3.7 mi | Colorado Springs, CO | ★★★☆☆ | 3/5 | |
| Bear Creek Senior Living | 4.4 mi | Colorado Springs, CO | ★★★★☆ | 4/5 | |
| Falcon Heights Rehabilitation and Nursing LLC | 4.5 mi | Colorado Springs, CO | ★★☆☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 065415.