Pikes Peak Post Acute

In the surveyor’s words

From the most serious findings on record at Pikes Peak Post Acute, in the surveyor’s own words.

• Actual harm, patternF692Sep 5, 2023

  Based on record review, observation and interviews, the facility failed to ensure five (#116, #31, #111, #87 and #26) of nine out of 70 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to identify and put nutritional interventions in place to prevent severe weight loss for Resident #31, Resident #111, Resident #26 and Resident #116; and a gradual weight loss for Resident #87. Record review, observations and interviews revealed the facility failed to implement nutritional interventions to address significant weight loss which turned into severe weight loss. […]

• Actual harm, isolatedF600Sep 17, 2024

  Based on record review and interviews, the facility failed to ensure four (#2, #9, #10 and #8) of four resident reviewed for abuse out of 10 sample residents were kept free from abuse. Specifically, the facility failed to ensure multiple residents, including Resident #2 and Resident #8, were kept free from physical abuse by addressing Resident #1's physically aggressive behavior. Resident #1 physically assaulted Resident #2 on four occasions and continuously targeted Resident #2. The facility was aware Resident #1 was territorial over his space and did not like to be touched. […]

• Actual harm, isolatedF657Nov 29, 2023

  Based on record review and interviews, the facility failed to revise the care plan for one resident (#1) out of three residents reviewed, to reflect, respond, and alert staff to the resident's behaviors that placed Resident #3 and others at risk for harm. Record review revealed on 10/13/23 at approximately 5:30 a.m., a certified nurse aide (CNA) entered Resident #1's room and found Resident #1 sitting in his chair next to the bed of his roommate, Resident #3. Resident #1 was holding a foot pedal to his wheelchair and his roommate had injuries to his face and body. Further record review revealed two days earlier, on 10/11/23, Resident #1 had transferred to the memory unit and into a room with Resident #3 who used a continuous positive airway pressure (CPAP) machine and oxygen at night. […]

• Actual harm, isolatedF550Oct 19, 2022

  Based on observations, interviews and record review, the facility failed to ensure six (#5, #9, #10, #7, #6 and #8) of 10 residents reviewed for dignity out of 10 sample residents had the right to a dignified existence. The facility failed to ensure residents experienced a dignified living experience by not promptly answering call lights for Resident #5, Resident #9 and Resident #10. Resident #5 was admitted to the facility on [DATE]. She needed extensive assistance with activities of daily living (ADLs). The resident required assistance with incontinence care and was concerned that staff would not promptly answer her call light. On 10/18/22 at 3:15 a.m. the resident was observed lying in bed with her call light initiated. The resident was interviewed on 10/18/22 at 3:30 p.m. […]

• Actual harm, isolatedF684Mar 23, 2021

  Based on record review, observations and family and staff interviews, the facility failed to ensure five (#63, #62, #79, #123 and #71) residents out of 62 sample residents received treatment and services necessary in accordance with professional standards of practice. Specifically: Resident #123, who was receiving anticoagulant medication, was found on the floor after an unwitnessed fall on [DATE] at 1:40 p.m. (Cross-reference F689) The facility failed to accurately and timely document and monitor Resident #123's neurological status after the fall, as well as, signs and symptoms of bleeding. An initial assessment by a registered nurse (RN) was followed by an assessment by a licensed practical nurse (LPN) 41 minutes later. […]