Cycle 1
Health 2025-12-11 · Fire 2025-12-11
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
13 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Colorado Springs, CO
Mountain View Post Acute
1-star overall rating with 1-star inspections with abuse icon flag with $29,224 in total fines with 13 recent health deficiencies with 13 fire-safety deficiencies in the latest cycle
835 Tenderfoot Hill Rd, Colorado Springs, CO
(719) 576-8380
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
180
Certified beds
Average residents
152
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Pacs Group
Operator or chain grouping
Approved since
1977-12-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
264 facilities
Chain averages 3 overall / 3 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.69
Registered nurse staffing · state 0.83 · national 0.68
LPN hours / resident day
0.64
Licensed practical nurse staffing · state 0.68 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.33
All reported nurse hours · state 3.70 · national 3.89
Licensed hours
1.33
RN + LPN hours · state 1.51 · national 1.54
Weekend hours
2.90
Weekend nurse staffing · state 3.26 · national 3.43
Weekend RN hours
0.52
Weekend registered nurse coverage · state 0.60 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.09 · national 0.07
Adjusted RN hours
0.72
CMS adjusted RN staffing hours
Adjusted total hours
3.48
CMS adjusted total nurse staffing hours
Case-mix index
1.31
Higher values indicate more complex resident acuity
RN turnover
56%
Annual RN turnover · state 46% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
11,099
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.02
Composite VBP score used to determine payment impact.
Payment multiplier
0.9819
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
2.39
Baseline 54.05% · Performance 53.91% · Measure score 2.39 · Achievement 2.39 · Improvement 0
Adjusted total nurse staffing
1.21
Baseline 3.73 hours · Performance 3.42 hours · Measure score 1.21 · Achievement 1.21 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.23% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 47 · Observed rate 10.64% · Lower 95% interval 6.66% |
| Discharge to community | 54.24% |
50.57%
3.7 pts better
|
No Different than the National Rate · Eligible stays 33 · Observed rate 45.45% · Lower 95% interval 37.87% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.14% |
95.27%
1.9 pts better
|
Numerator 34 · Denominator 35 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 35 |
| Discharge self-care score | 61.54% |
53.69%
7.9 pts better
|
Numerator 16 · Denominator 26 |
| Discharge mobility score | 42.31% |
50.94%
8.6 pts worse
|
Numerator 11 · Denominator 26 |
| Pressure ulcers or injuries, new or worsened | 2.86% |
2.29%
0.6 pts worse
|
Numerator 1 · Denominator 35 · Adjusted rate 2.8% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 16 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 1.44% |
8.2%
6.8 pts worse
|
Numerator 3 · Denominator 209 |
| Staff flu vaccination coverage | 79.77% |
42%
37.8 pts better
|
Numerator 205 · Denominator 257 |
| Discharge function score | 65.38% |
56.45%
8.9 pts better
|
Numerator 17 · Denominator 26 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 17 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 1 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 19 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.2 |
1.3
0.1 pts better
|
1.9
0.7 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.5 · Expected 2.2 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.9 |
1.7
0.2 pts worse
|
1.8
0.1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 1.9 · Observed 1.8 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 94.6% |
93.5%
1.1 pts better
|
93.4%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 94.1% · Q2 95.4% · Q3 93.1% · Q4 95.7% · 4Q avg 94.6% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 97.2% |
94.7%
2.5 pts better
|
95.5%
1.7 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 97.2% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.9% |
3.4%
1.5 pts better
|
3.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 1.5% · Q3 2.3% · Q4 1.4% · 4Q avg 1.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 2.5% |
7.4%
4.9 pts better
|
11.4%
8.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.6% · Q2 0.8% · Q3 0.8% · Q4 5.5% · 4Q avg 2.5% |
| Percentage of long-stay residents who lose too much weight | 1.9% |
5.0%
3.1 pts better
|
5.4%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 2.7% · Q3 2.6% · Q4 0.8% · 4Q avg 1.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 10.1% |
11.2%
1.1 pts better
|
19.6%
9.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.9% · Q2 9.5% · Q3 11.4% · Q4 10.7% · 4Q avg 10.1% |
| Percentage of long-stay residents who received an antipsychotic medication | 19.4% |
20.6%
1.2 pts better
|
16.7%
2.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 20.0% · Q3 19.2% · Q4 19.2% · 4Q avg 19.4% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 25.4% |
15.2%
10.2 pts worse
|
16.3%
9.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 35.5% · Q2 25.0% · Q3 23.0% · Q4 17.6% · 4Q avg 25.4% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.0% |
14.6%
4.6 pts better
|
14.9%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.3% · Q2 4.4% · Q3 11.6% · Q4 10.3% · 4Q avg 10.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.1% |
0.8%
0.3 pts worse
|
1.0%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 3.1% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.5%
0.4 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.8% · Q3 0.0% · Q4 2.9% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.2% |
22.4%
6.8 pts worse
|
19.8%
9.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.0% · Q2 22.3% · Q3 32.6% · Q4 31.3% · 4Q avg 29.2% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
3.7%
0.4 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.5% · Q3 1.6% · Q4 5.5% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 65.9% |
76.4%
10.5 pts worse
|
81.7%
15.8 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 46.6% · Q2 45.8% · Q3 76.7% · Q4 90.7% · 4Q avg 65.9% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.0% |
12.8%
5.8 pts better
|
12.0%
5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.0% · Observed 7.4% · Expected 11.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 4.1% |
1.5%
2.6 pts worse
|
1.6%
2.5 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 7.5% · Q4 3.8% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 61.2% |
75.6%
14.4 pts worse
|
79.7%
18.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 61.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.5% |
20.3%
2.2 pts worse
|
23.9%
1.4 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.5% · Observed 25.9% · Expected 27.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
26 health deficiencies
Top issue: Quality of Life and Care (10 deficiencies)
11 fire-safety deficiencies
Top issue: Emergency Preparedness (4 deficiencies)
Cycle 3
Health 2022-07-28 · Fire 2022-07-28
21 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
16 fire-safety deficiencies
Top issue: Smoke (7 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-12-11
K161 · Construction Deficiencies
Fire Safety
Use approved construction type or materials.
Corrected 2026-02-10
F · Potential for more than minimal harm
2025-12-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2026-02-20
F · Potential for more than minimal harm
2025-12-11
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2026-02-10
F · Potential for more than minimal harm
2025-12-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2026-02-10
F · Potential for more than minimal harm
2025-12-11
K500 · Services Deficiencies
Fire Safety
Meet other general requirements that are deficient.
Corrected 2026-02-06
F · Potential for more than minimal harm
2025-12-11
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2026-02-06
F · Potential for more than minimal harm
2025-12-11
K914 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.
Corrected 2026-02-06
F · Potential for more than minimal harm
2025-12-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-12-11
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2026-02-10
E · Potential for more than minimal harm
2025-12-11
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2026-02-06
E · Potential for more than minimal harm
2025-12-11
K927 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper fire barriers, ventilation and signs for the transfilling of oxygen.
Corrected 2026-02-20
D · Potential for more than minimal harm
2025-12-11
K311 · Smoke Deficiencies
Fire Safety
Have an enclosure around a vertical opening shaft.
Corrected 2026-02-06
D · Potential for more than minimal harm
2025-12-11
K751 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of flammable curtains.
Corrected 2026-02-06
F · Potential for more than minimal harm
2023-11-16
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-16
E36 · Emergency Preparedness Deficiencies
Fire Safety
Establish emergency prep training and testing.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-16
E37 · Emergency Preparedness Deficiencies
Fire Safety
Establish staff and initial training requirements.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-16
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-16
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-02-15
F · Potential for more than minimal harm
2023-11-16
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-01-12
F · Potential for more than minimal harm
2023-11-16
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-01-12
E · Potential for more than minimal harm
2023-11-16
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-11-16
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-11-16
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-01-12
D · Potential for more than minimal harm
2023-11-16
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-01-12
F · Potential for more than minimal harm
2022-07-28
K111 · Construction Deficiencies
Fire Safety
Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.
Corrected 2022-09-17
F · Potential for more than minimal harm
2022-07-28
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2022-09-17
F · Potential for more than minimal harm
2022-07-28
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-09-17
F · Potential for more than minimal harm
2022-07-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-02-14
F · Potential for more than minimal harm
2022-07-28
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2022-09-17
F · Potential for more than minimal harm
2022-07-28
K351 · Smoke Deficiencies
Fire Safety
Install an approved automatic sprinkler system.
Corrected 2023-02-14
F · Potential for more than minimal harm
2022-07-28
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-02-14
F · Potential for more than minimal harm
2022-07-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2022-09-17
F · Potential for more than minimal harm
2022-07-28
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2022-09-17
E · Potential for more than minimal harm
2022-07-28
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2022-09-17
E · Potential for more than minimal harm
2022-07-28
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2022-09-17
E · Potential for more than minimal harm
2022-07-28
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-09-17
E · Potential for more than minimal harm
2022-07-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-09-17
E · Potential for more than minimal harm
2022-07-28
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-02-14
E · Potential for more than minimal harm
2022-07-28
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-02-14
E · Potential for more than minimal harm
2022-07-28
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2022-09-17
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-12-11
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-01-28
F · Potential for more than minimal harm
2025-12-11
F923 · Environmental Deficiencies
Health
Have enough outside ventilation via a window or mechanical ventilation, or both.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-12-11
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-12-11
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-12-11
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-12-11
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-12-11
F947 · Nursing and Physician Services Deficiencies
Health
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-11
F552 · Resident Rights Deficiencies
Health
Ensure that residents are fully informed and understand their health status, care and treatments.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-11
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-11
F685 · Quality of Life and Care Deficiencies
Health
Assist a resident in gaining access to vision and hearing services.
Corrected 2026-01-28
D · Potential for more than minimal harm
2025-12-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-01-28
E · Potential for more than minimal harm
2025-04-16
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-04-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-05-16
D · Potential for more than minimal harm
2025-02-26
F742 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.
Corrected 2025-04-01
E · Potential for more than minimal harm
2024-09-05
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-10
D · Potential for more than minimal harm
2024-09-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-05
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-09-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-27
D · Potential for more than minimal harm
2024-02-05
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-02-23
G · Actual harm
2023-11-16
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-12-15
G · Actual harm
2023-11-16
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-16
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-16
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-11-16
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-16
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-16
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-16
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-11-16
F744 · Quality of Life and Care Deficiencies
Health
Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F640 · Resident Assessment and Care Planning Deficiencies
Health
Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F679 · Quality of Life and Care Deficiencies
Health
Provide activities to meet all resident's needs.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F806 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-12-15
E · Potential for more than minimal harm
2023-09-27
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-27
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-27
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-09-27
F807 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-27
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-27
F691 · Quality of Life and Care Deficiencies
Health
Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.
Corrected 2023-10-27
D · Potential for more than minimal harm
2023-09-27
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-10-27
G · Actual harm
2023-03-02
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-27
E · Potential for more than minimal harm
2023-03-02
F561 · Resident Rights Deficiencies
Health
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Corrected 2023-04-02
E · Potential for more than minimal harm
2023-03-02
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-04-02
D · Potential for more than minimal harm
2023-03-02
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-04-02
F · Potential for more than minimal harm
2022-07-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-08-28
E · Potential for more than minimal harm
2022-07-28
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2022-08-28
E · Potential for more than minimal harm
2022-07-28
F804 · Nutrition and Dietary Deficiencies
Health
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Corrected 2022-08-28
E · Potential for more than minimal harm
2022-07-28
F809 · Nutrition and Dietary Deficiencies
Health
Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-28
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-28
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2022-08-28
D · Potential for more than minimal harm
2022-07-28
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2022-08-28
Penalties and ownership
What sits behind the stars
$29,224
2023-11-16
Fine
Fine · fine $29,224
Fine
Ownership
Panther Master Tenant, LLC
5% Or Greater Direct Ownership Interest · Organization
Apt, Frederick
Corporate Officer · Individual
Hancock, Mark
5% Or Greater Indirect Ownership Interest · Individual
Hancock, Mark
Corporate Officer · Individual
Jergensen, Joshua
Corporate Officer · Individual
Mitchell, John
Corporate Officer · Individual
Murray, Jason
5% Or Greater Indirect Ownership Interest · Individual
Pacs Group, Inc.
5% Or Greater Indirect Ownership Interest · Organization
Pacs Holdings, LLC
5% Or Greater Indirect Ownership Interest · Organization
Providence Group Nh, LLC
5% Or Greater Indirect Ownership Interest · Organization
Shepherd, David
Contracted Managing Employee · Individual
Tuttle, Cameron
W-2 Managing Employee · Individual
Nearby options
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Falcon Heights Rehabilitation And Nursing LLC
Colorado Springs, CO
2-star overall rating with 2-star inspections with abuse icon flag with $6,146 in total fines with 16 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#2
Fountain View Rehabilitation And Nursing LLC
Colorado Springs, CO
1-star overall rating with 2-star inspections with $12,968 in total fines with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
Medallion Post Acute Rehabilitation
Colorado Springs, CO
1-star overall rating with 1-star inspections with $86,723 in total fines with 16 recent health deficiencies with 12 fire-safety deficiencies in the latest cycle
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