Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record

MOUNTAIN VIEW POST ACUTE

COLORADO SPRINGS, CO · 180 certified beds · Last Life Safety survey December 11, 2025

CMS Certification Number 065147 · first certified December 1977

Ownership

Operated by PACS GROUP · For profit - Limited Liability company

Ownership changed September 1, 2023 (change of ownership)from PEAK MEDICAL COLORADO NO. 2, LLC

Citations on file

Rolling three-year window

Life Safety surveys

In the same window

Tags cited more than once

Across separate surveys

Inspection & testing records

Of the citations on file

Position within CO

40 citations — more than 98% of the 210 certified nursing homes in CO. Compared within CO rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated

Holding steadyabout the same at the latest survey as at its earlier surveys in the window.

The latest survey found 13 citations; the earlier surveys in the window averaged 13.5. With 3 surveys on file this is a direction of travel, not a conclusion.

When is the next survey likely?

The window opens May 2027 — about 8 months from now. This facility’s last Life Safety survey was December 2025. Facilities in CO are typically surveyed 17–24 months after the last one (median 19), measured over 177 consecutive surveys in the last two years of CMS records.

A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured

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3 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.

Emergency preparedness

4 of the 40 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index

Physical environment (health survey)

11 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 40 Life Safety citations above. The Physical Environment Index

F-0584 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.
F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
F-0880 Provide and implement an infection prevention and control program.
F-0923 Have enough outside ventilation via a window or mechanical ventilation, or both.
F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

How that compares

Citations on file over three years

Compared with the median facility in CO, and nationally. Surveyors differ markedly between states, so the CO figure is the meaningful one.

Citations on file over three years, compared
Measure	Citations
This facility	40
Median facility in CO	16
Median facility nationally	11

Survey history

Citations at each Life Safety survey

Citations at each Life Safety survey
Survey date	Citations
July 28, 2022	16
November 16, 2023	11
December 11, 2025	13

Most-cited tags

Most-cited tags at this facility

Most-cited tags at this facility
Tag	What the surveyor checks	Times cited	Last cited
K-0222	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.	3	2025-12-11
K-0353	Inspect, test, and maintain automatic sprinkler systems.	3	2025-12-11
K-0324	Provide properly protected cooking facilities.	2	2025-12-11
K-0293	Have properly located and lighted "Exit" signs.	2	2023-11-16
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	2	2023-11-16
K-0363	Install corridor and hallway doors that block smoke.	2	2025-12-11
E-0036	Establish emergency prep training and testing.	1	2023-11-16
K-0751	Have restrictions on the use of flammable curtains.	1	2025-12-11

What the citations cover

Citations by CMS category

Smoke Deficiencies 16
Egress Deficiencies 7
Gas, Vacuum, and Electrical Systems Deficiencies 4
Miscellaneous Deficiencies 4
Other 9

Citations by CMS category
Category	Citations
Smoke Deficiencies	16
Egress Deficiencies	7
Gas, Vacuum, and Electrical Systems Deficiencies	4
Miscellaneous Deficiencies	4
Emergency Preparedness Deficiencies	4
Services Deficiencies	3
Construction Deficiencies	2

Every citation on file

As published by CMS, newest survey first. Descriptions are CMS’s own wording.

December 11, 2025 — 13 citations

Citations issued on December 11, 2025
Tag	What the surveyor checks	Status
K-0161	Use approved construction type or materials.	Deficient, Provider has date of correction (January 7, 2026)
K-0222	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.	Deficient, Provider has date of correction (February 10, 2026)
K-0311	Have an enclosure around a vertical opening shaft.	Deficient, Provider has date of correction (February 6, 2026)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has plan of correction
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has plan of correction
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (February 10, 2026)
K-0372	Ensure smoke barriers are constructed to a 1 hour fire resistance rating.	Deficient, Provider has plan of correction
K-0500	Meet other general requirements that are deficient.	Deficient, Provider has date of correction (February 6, 2026)
K-0741	Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.	Deficient, Provider has date of correction (March 11, 2026)
K-0751	Have restrictions on the use of flammable curtains.	Deficient, Provider has date of correction (March 11, 2026)
K-0914	Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.	Deficient, Provider has date of correction (March 11, 2026)
K-0918	Have generator or other power source capable of supplying service within 10 seconds.	Deficient, Provider has date of correction (February 6, 2026)
K-0927	Have proper fire barriers, ventilation and signs for the transfilling of oxygen.	Deficient, Provider has plan of correction

November 16, 2023 — 11 citations

Citations issued on November 16, 2023
Tag	What the surveyor checks	Status
E-0030	List the names and contact information of those in the facility.	Deficient, Provider has date of correction (December 15, 2023)
E-0036	Establish emergency prep training and testing.	Deficient, Provider has date of correction (December 15, 2023)
E-0037	Establish staff and initial training requirements.	Deficient, Provider has date of correction (December 15, 2023)
E-0039	Conduct testing and exercise requirements.	Deficient, Provider has date of correction (December 15, 2023)
K-0222	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.	Deficient, Provider has date of correction (January 12, 2024)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (January 12, 2024)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Deficient, Provider has date of correction (January 12, 2024)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Deficient, Provider has date of correction (February 15, 2024)
K-0355	Properly select, install, inspect, or maintain portable fire extinguishes.	Deficient, Provider has date of correction (January 12, 2024)
K-0363	Install corridor and hallway doors that block smoke.	Deficient, Provider has date of correction (January 12, 2024)
K-0712	Have simulated fire drills held at unexpected times.	Deficient, Provider has date of correction (January 12, 2024)

July 28, 2022 — 16 citations

Citations issued on July 28, 2022
Tag	What the surveyor checks	Status
K-0111	Satisfy building requirements after a repair, renovation, modification, or change of user/occupancy.	Deficient, Provider has date of correction (September 17, 2022)
K-0211	Keep aisles, corridors, and exits free of obstruction in case of emergency.	Deficient, Provider has date of correction (September 17, 2022)
K-0222	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.	Deficient, Provider has date of correction (September 17, 2022)
K-0291	Install emergency lighting that can last at least 1 1/2 hours.	Deficient, Provider has date of correction (September 17, 2022)
K-0293	Have properly located and lighted "Exit" signs.	Deficient, Provider has date of correction (September 17, 2022)
K-0321	Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.	Waiver has been granted (February 14, 2023)
K-0324	Provide properly protected cooking facilities.	Deficient, Provider has date of correction (September 17, 2022)
K-0325	Have properly installed hallway dispensers for alcohol-based hand rub.	Deficient, Provider has date of correction (September 17, 2022)
K-0345	Have approved installation, maintenance and testing program for fire alarm systems.	Deficient, Provider has date of correction (September 17, 2022)
K-0351	Install an approved automatic sprinkler system.	Waiver has been granted (February 14, 2023)
K-0353	Inspect, test, and maintain automatic sprinkler systems.	Waiver has been granted (February 14, 2023)
K-0361	Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.	Waiver has been granted (February 14, 2023)
K-0511	Have properly installed electrical wiring and gas equipment.	Deficient, Provider has date of correction (September 17, 2022)
K-0521	Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Waiver has been granted (February 14, 2023)
K-0753	Have restrictions on the use of highly flammable decorations.	Deficient, Provider has date of correction (September 17, 2022)
K-0912	Have power receptacles that are properly grounded.	Deficient, Provider has date of correction (September 17, 2022)

Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.