PIKES PEAK POST ACUTE
2719 N UNION BLVD
COLORADO SPRINGS, CO, 80909
7196361676
CCN: 065415
1
Overall1
Health3
Staffing3
QualitySpecial FocusAbuse IconOwnership Changed (12mo)Inspection OverdueOIG ExcludedUnder CIA
Ownership
| Name | Role | % |
|---|---|---|
| PANTHER MASTER TENANT, LLC | 5% OR GREATER DIRECT OWNERSHIP INTEREST | 100% |
| PACS HOLDINGS, LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| PROVIDENCE GROUP NH, LLC | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| PACS GROUP, INC. | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| HANCOCK, MARK | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| MURRAY, JASON | 5% OR GREATER INDIRECT OWNERSHIP INTEREST | NO PERCENTAGE PROVIDED |
| SHEPHERD, DAVID | CONTRACTED MANAGING EMPLOYEE | NOT APPLICABLE |
| APT, FREDERICK | CORPORATE OFFICER | NOT APPLICABLE |
| HANCOCK, MARK | CORPORATE OFFICER | NOT APPLICABLE |
| JERGENSEN, JOSHUA | CORPORATE OFFICER | NOT APPLICABLE |
| MITCHELL, JOHN | CORPORATE OFFICER | NOT APPLICABLE |
| CREASON, JONATHAN | W-2 MANAGING EMPLOYEE | NOT APPLICABLE |
Penalties (4)
| Date | Type | Amount |
|---|---|---|
| 2024-09-17 | Fine | $40K |
| 2024-09-17 | Payment Denial | 28 days |
| 2023-09-05 | Fine | $49K |
| 2023-09-05 | Payment Denial | 63 days |
Health Deficiencies (47)
2025-11-20 · Health
D
F744 · Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
D
F600 · 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.
2025-01-30 · Health
D
F921 · Environmental Deficiencies
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
E
F730 · Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
D
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F685 · Quality of Life and Care Deficiencies
Assist a resident in gaining access to vision and hearing services.
D
F677 · Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
D
F600 · 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.
E
F585 · 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.
D
F561 · Resident Rights Deficiencies
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
D
F558 · Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
2024-09-17 · Health
E
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Respond appropriately to all alleged violations.
E
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
G
F600 · 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.
2024-03-14 · Health
E
F695 · Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
2023-11-29 · Health
G
F657 · 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.
D
F559 · 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.
D
F552 · Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
2023-09-05 · Health
E
F881 · Infection Control Deficiencies
Implement a program that monitors antibiotic use.
E
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
F
F867 · Administration Deficiencies
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.
F
F838 · 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.
F
F812 · Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
D
F806 · 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.
F
F803 · 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.
E
F761 · 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.
E
F759 · Pharmacy Service Deficiencies
Ensure medication error rates are not 5 percent or greater.
E
F744 · Quality of Life and Care Deficiencies
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
D
F712 · Nursing and Physician Services Deficiencies
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
H
F692 · Quality of Life and Care Deficiencies
Provide enough food/fluids to maintain a resident's health.
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F688 · 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.
D
F686 · Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
D
F679 · Quality of Life and Care Deficiencies
Provide activities to meet all resident's needs.
D
F676 · 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.
D
F658 · Resident Assessment and Care Planning Deficiencies
Ensure services provided by the nursing facility meet professional standards of quality.
D
F600 · 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.
E
F567 · Resident Rights Deficiencies
Honor the resident's right to manage his or her financial affairs.
E
F565 · Resident Rights Deficiencies
Honor the resident's right to organize and participate in resident/family groups in the facility.
D
F554 · Resident Rights Deficiencies
Allow residents to self-administer drugs if determined clinically appropriate.
2022-06-10 · Health
D
F880 · Infection Control Deficiencies
Provide and implement an infection prevention and control program.
D
F690 · Quality of Life and Care Deficiencies
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
E
F689 · Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
D
F684 · Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
D
F657 · 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.
D
F645 · Resident Assessment and Care Planning Deficiencies
PASARR screening for Mental disorders or Intellectual Disabilities
Staffing
MetricThis FacilityNational Avg
Total Nurse Hrs/Resident/Day3.68
3.34
RN Hrs/Resident/Day0.54
0.66
LPN Hrs/Resident/Day0.81
0.80
CNA Hrs/Resident/Day2.33
1.88
PT Hrs/Resident/Day0.12
0.05
Data as of 2026-03-01