ElderGrade

Inspection citations at Pikes Peak Post Acute

47 citations on record, 3 of which inspectors scored at actual harm or immediate jeopardy. Each one is the state surveyor's own finding, not our summary.

Reading the scope & severity code

A–C

No harm, minimal potential

D–F

No harm, potential for harm

G–I

Actual harm to a resident

J–L

Immediate jeopardy

The letter also encodes how many residents were affected — isolated, a pattern, or widespread. Full explainer.

Citations by survey year

Year Citations Involving harm or jeopardy
2025 12 0
2024 4 1
2023 25 2
2022 6 0
D November 20, 2025 Tag F0744 Complaint investigation Corrected Dec 2025

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

No actual harm, potential for more than minimal harm

D November 20, 2025 Tag F0600 Complaint investigation Corrected Dec 2025

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.

No actual harm, potential for more than minimal harm

D January 30, 2025 Tag F0921 Corrected Feb 2025

Environmental Deficiencies

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

No actual harm, potential for more than minimal harm

D January 30, 2025 Tag F0880 Complaint investigation Corrected Feb 2025

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

D January 30, 2025 Tag F0689 Corrected Feb 2025

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

D January 30, 2025 Tag F0685 Corrected Feb 2025

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

No actual harm, potential for more than minimal harm

D January 30, 2025 Tag F0677 Corrected Feb 2025

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

No actual harm, potential for more than minimal harm

D January 30, 2025 Tag F0600 Corrected Feb 2025

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.

No actual harm, potential for more than minimal harm

D January 30, 2025 Tag F0561 Corrected Feb 2025

Resident Rights Deficiencies

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

No actual harm, potential for more than minimal harm

D January 30, 2025 Tag F0558 Corrected Feb 2025

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

No actual harm, potential for more than minimal harm

E January 30, 2025 Tag F0730 Corrected Feb 2025

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

No actual harm, potential for more than minimal harm

E January 30, 2025 Tag F0585 Corrected Feb 2025

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.

No actual harm, potential for more than minimal harm

E September 17, 2024 Tag F0610 Complaint investigation Corrected Nov 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

No actual harm, potential for more than minimal harm

E September 17, 2024 Tag F0609 Complaint investigation Corrected Nov 2024

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

No actual harm, potential for more than minimal harm

G September 17, 2024 Tag F0600 Complaint investigation Corrected Sep 2024

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.

Actual harm to a resident

E March 14, 2024 Tag F0695 Complaint investigation Corrected Apr 2024

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

No actual harm, potential for more than minimal harm

D November 29, 2023 Tag F0559 Complaint investigation Corrected Nov 2023

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.

No actual harm, potential for more than minimal harm

D November 29, 2023 Tag F0552 Complaint investigation Corrected Nov 2023

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

No actual harm, potential for more than minimal harm

G November 29, 2023 Tag F0657 Complaint investigation Corrected Nov 2023

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.

Actual harm to a resident

D September 5, 2023 Tag F0806 Corrected Sep 2023

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

D September 5, 2023 Tag F0712 Corrected Sep 2023

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

No actual harm, potential for more than minimal harm

D September 5, 2023 Tag F0688 Corrected Oct 2023

Quality of Life and Care Deficiencies

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.

No actual harm, potential for more than minimal harm

D September 5, 2023 Tag F0686 Corrected Nov 2023

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

No actual harm, potential for more than minimal harm

D September 5, 2023 Tag F0679 Corrected Sep 2023

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

No actual harm, potential for more than minimal harm

D September 5, 2023 Tag F0676 Corrected Sep 2023

Quality of Life and Care Deficiencies

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

No actual harm, potential for more than minimal harm

D September 5, 2023 Tag F0658 Corrected Nov 2023

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

No actual harm, potential for more than minimal harm

D September 5, 2023 Tag F0600 Corrected Nov 2023

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.

No actual harm, potential for more than minimal harm

D September 5, 2023 Tag F0554 Corrected Sep 2023

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

No actual harm, potential for more than minimal harm

E September 5, 2023 Tag F0881 Corrected Sep 2023

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

No actual harm, potential for more than minimal harm

E September 5, 2023 Tag F0880 Corrected Nov 2023

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

No actual harm, potential for more than minimal harm

E September 5, 2023 Tag F0761 Corrected Dec 2023

Pharmacy Service Deficiencies

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.

No actual harm, potential for more than minimal harm

E September 5, 2023 Tag F0759 Corrected Sep 2023

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

No actual harm, potential for more than minimal harm

E September 5, 2023 Tag F0744 Corrected Nov 2023

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

No actual harm, potential for more than minimal harm

E September 5, 2023 Tag F0689 Corrected Sep 2023

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

No actual harm, potential for more than minimal harm

E September 5, 2023 Tag F0567 Corrected Sep 2023

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

No actual harm, potential for more than minimal harm

E September 5, 2023 Tag F0565 Corrected Nov 2023

Resident Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

No actual harm, potential for more than minimal harm

F September 5, 2023 Tag F0867 Corrected Nov 2023

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

No actual harm, potential for more than minimal harm

F September 5, 2023 Tag F0838 Corrected Nov 2023

Administration Deficiencies

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.

No actual harm, potential for more than minimal harm

F September 5, 2023 Tag F0812 Corrected Sep 2023

Nutrition and Dietary Deficiencies

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

No actual harm, potential for more than minimal harm

F September 5, 2023 Tag F0803 Corrected Sep 2023

Nutrition and Dietary Deficiencies

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.

No actual harm, potential for more than minimal harm

Citations are published by CMS from state survey agency findings. A citation describes what an inspector observed on a specific date; homes are required to submit a correction plan, and many findings are resolved long before you read them. Ask the administrator what happened and what changed.