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Deficiency Records for Pikes Peak Post Acute
A list of the most recent deficiencies for Pikes Peak Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Pikes Peak Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-09-17 | 2024-09-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-09-17 | 2024-09-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2024-09-17 | 2024-09-18 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-14 | 2024-04-12 | Y |
| 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. | Health | 2023-09-05 | 2023-12-04 | N |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2023-11-29 | 2023-11-30 | Y |
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2023-11-29 | 2023-11-30 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-11-29 | 2023-11-30 | Y |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-09-05 | 2023-11-15 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-09-05 | 2023-11-15 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-09-05 | 2023-11-15 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2023-09-05 | 2023-11-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-05 | 2023-11-15 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-05 | 2023-11-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-05 | 2023-11-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-05 | 2023-11-05 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-09-05 | 2023-11-05 | N |
| 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. | Health | 2023-09-05 | 2023-10-30 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-09-12 | 2023-10-15 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-12 | 2023-10-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-12 | 2023-10-15 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-09-12 | 2023-10-15 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-09-12 | 2023-10-15 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-12 | 2023-10-15 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-09-12 | 2023-09-30 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-09-05 | 2023-09-27 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-09-05 | 2023-09-27 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-05 | 2023-09-27 | N |
| Provide activities to meet all resident's needs. | Health | 2023-09-05 | 2023-09-27 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-05 | 2023-09-27 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2023-09-05 | 2023-09-27 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-09-05 | 2023-09-27 | N |
| 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. | Health | 2023-09-05 | 2023-09-27 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-09-05 | 2023-09-27 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-05 | 2023-09-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-09-05 | 2023-09-27 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-19 | 2022-11-18 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-10-19 | 2022-11-18 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-10-19 | 2022-11-18 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-28 | 2022-08-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-28 | 2022-07-31 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-28 | 2022-07-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2022-06-10 | 2022-07-15 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-06-10 | 2022-07-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-06-10 | 2022-07-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-10 | 2022-07-15 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-06-10 | 2022-07-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-06-28 | 2022-07-15 | N |
| Install proper backup exit lighting. | Fire Safety | 2022-06-28 | 2022-07-15 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2022-06-28 | 2022-07-15 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-06-10 | 2022-07-12 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-28 | 2022-07-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-28 | 2022-06-30 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-06-28 | 2022-06-29 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-01-20 | 2022-02-25 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-01-20 | 2022-02-25 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-01-20 | 2022-02-25 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-20 | 2022-02-25 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-01-20 | 2022-02-25 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2022-01-20 | 2022-02-25 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-20 | 2022-02-25 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-20 | 2022-02-21 | Y |
| Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. | Health | 2021-03-23 | 2021-04-30 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-03-23 | 2021-04-30 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-03-23 | 2021-04-30 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-03-23 | 2021-04-30 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-03-23 | 2021-04-30 | N |
| Provide activities to meet all resident's needs. | Health | 2021-03-23 | 2021-04-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-23 | 2021-04-30 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-03-23 | 2021-04-30 | N |
| Provide appropriate foot care. | Health | 2021-03-23 | 2021-04-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-23 | 2021-04-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-03-23 | 2021-04-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-03-23 | 2021-04-30 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-03-23 | 2021-04-30 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-03-23 | 2021-04-30 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-03-23 | 2021-04-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-23 | 2021-04-30 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-03-23 | 2021-04-30 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-04-07 | 2021-04-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-04-07 | 2021-04-18 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-04-07 | 2021-04-15 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-04-07 | 2021-04-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-04-07 | 2021-04-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-04-07 | 2021-04-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-04-07 | 2021-04-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-04-07 | 2021-04-07 | N |
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