Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Atlas Post Acute during CMS and state inspections, most recent first.
A resident with chronic pain, osteoarthritis, contractures, and lower leg wounds had orders for scheduled and PRN oxycodone, with a care plan directing that pain medications be administered as ordered. Over several days, multiple doses of the resident’s scheduled immediate-release oxycodone were not given, with documentation indicating the drug was on order or not on hand and no documented notification to the provider when it was unavailable. The resident reported missing pain doses several times, experiencing increased pain and withdrawal-like symptoms, and being told staff were waiting for the pharmacy. Staff interviews revealed inconsistent understanding and execution of the medication re-ordering and provider-notification process, and facility leadership later acknowledged that one missed dose occurred despite adequate stock and without documented reason or provider contact.
A resident with multiple medical conditions was administered Midodrine for hypotension without consistent adherence to physician-ordered BP parameters. The medication was given multiple times without a BP check or when BP readings were outside the prescribed range, and was also withheld when it should have been administered. Staff interviews confirmed confusion about the medication parameters and failure to follow required procedures.
The facility failed to honor dietary preferences for three residents, leading to deficiencies in meal service. A resident with diabetes did not receive hard boiled eggs as requested, another resident requiring small portions due to dental issues was served regular portions, and a third resident with malnutrition did not receive double portions of preferred foods. Staff interviews and record reviews confirmed these lapses in adhering to documented preferences.
The facility failed to properly label and store medications on two medication carts, with insulin pens and inhalers lacking open dates. An LPN confirmed that insulin should be dated upon opening to ensure timely disposal, while another LPN found insulin pens past their 28-day usage period. The DON acknowledged the importance of labeling medications with open dates to maintain their effectiveness.
A resident with dementia and muscle weakness was observed with long, dirty fingernails despite needing assistance with ADLs. The facility's policy required regular nail care to prevent infections and skin issues, but the resident's nails were not trimmed or cleaned for months. Staff interviews confirmed the resident's dependency on staff for nail care and the associated risks of neglecting this care.
A facility failed to ensure proper monitoring and care planning for a resident using a continuous glucose monitor (CGM). The resident, with Type I diabetes, was not effectively monitored for CGM changes, and staff lacked training on its use. The care plan did not address the CGM, and physician's orders were incomplete. Interviews revealed staff confusion and lack of training, with the DON acknowledging the need for better tracking and care planning.
A resident with multiple health conditions was observed receiving oxygen at 4 LPM, contrary to the physician's order of 3 LPM. Staff interviews revealed that CNAs were informed of oxygen rates but did not adjust settings, which was the responsibility of licensed nurses. An LPN confirmed the discrepancy and the DON emphasized the importance of following physician orders to prevent medical complications.
Failure to Administer Ordered Pain Medication and Notify Provider When Medication Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to provide pain medication as ordered and to notify the provider when a resident’s ordered pain medication was unavailable. Resident #2, who was cognitively intact and dependent on staff for transfers, toileting, bathing, and dressing, had diagnoses including protein calorie malnutrition, contractures of both knees, chronic pain syndrome, generalized osteoarthritis, and open wounds to both lower legs. Physician orders included scheduled extended-release oxycodone (Oxycontin) twice daily, scheduled immediate-release oxycodone (Roxicodone) every four hours for chronic pain, and PRN oxycodone for breakthrough pain, along with an order to monitor and document pain levels and use non-pharmacological interventions before PRN medication. The resident’s pain care plan identified him as at risk for pain or discomfort due to wounds and disease processes, with interventions to administer medications as ordered. Record review showed that multiple doses of the resident’s scheduled Roxicodone were not administered. On one day in January, four of six scheduled doses were not given, and another scheduled dose was not given on a later date, with the MAR indicating “other/see nurses notes” for several missed doses. Nursing progress notes documented that Roxicodone was on order and that nurses were unable to access the pyxis, and that there was none of the medication on hand despite reports that it had been reordered. One note also documented that the resident refused an offer to get up for an hour daily because he had no pain medication. For the missed dose on the later January date, there was no documentation in the nursing progress notes explaining why the medication was not administered. Interviews further described the circumstances around the missed pain medication. Resident #2 reported that he had missed his pain medication three or four times since admission, that missing his immediate-release oxycodone led to increased leg pain and withdrawal-like symptoms, and that staff told him the facility was waiting for the medication from the pharmacy when it was unavailable. An LPN stated she reordered medications when the card reached a certain level and relied on providers being present on weekdays, and she was unsure of the process on weekends or overnight. The DON and regional clinical resource stated that if a medication was unavailable, they expected nurses to notify the provider to consider a substitute or hold the medication and document the communication, and later acknowledged they were unsure why a dose was not administered on the later January date and that there was sufficient stock at that time. Staff interviews also confirmed that the resident frequently complained of pain and relied on timely administration of his pain medications, while the facility did not document provider notification when the ordered pain medication was unavailable.
Failure to Follow Medication Administration Parameters for Hypotension Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Midodrine, a medication prescribed for hypotension. According to physician orders, Midodrine was to be administered only if the resident's blood pressure (BP) was below 100/60 mmHg, and a BP reading was required prior to each dose. However, the medication administration records revealed that the resident received Midodrine multiple times without a BP being taken beforehand, and on several occasions, the medication was administered when the resident's BP was outside the prescribed parameters. There were also instances where the medication was not given when it should have been, according to the physician's orders. The resident involved was over 65 years old, had diagnoses including unspecified cirrhosis of the liver, muscle weakness, acute respiratory failure with hypoxia, and chronic hepatic failure, and was cognitively intact. The resident required significant assistance with activities of daily living and had a goal to discharge into the community. The medication errors occurred over several days, with the medication being given when the BP was above the threshold or withheld when it should have been administered, as documented in the medication administration records. Interviews with staff confirmed that the required BP checks were not consistently performed prior to administering the medication, and that the parameters for administration were not always followed. Nursing staff acknowledged confusion regarding the medication parameters and the necessity of BP measurement before administration. The facility's policy required medications to be administered as prescribed, including adherence to any parameters and documentation of medication errors, but these procedures were not followed in this case.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated resident preferences for three residents, leading to deficiencies in dietary services. Resident #38, who was on a therapeutic diet due to diabetes, consistently did not receive hard boiled eggs with his meals as per his preference. Despite his requests and the inclusion of this preference on his meal ticket, the staff failed to provide the eggs, indicating a breakdown in communication and adherence to dietary preferences. Interviews with staff revealed that the dietary manager and other staff were aware of the resident's preferences, but these were not consistently honored. Resident #18, who required a mechanically altered diet and preferred small meal portions due to dental issues, was served regular portions instead of the small portions she preferred. This discrepancy was observed during meal preparation and was not aligned with the resident's documented preferences on her meal ticket. The dietary manager acknowledged the oversight but was unaware of the specific incident, highlighting a lapse in ensuring that meal preferences were accurately followed. Resident #23, who had multiple health issues including severe protein-calorie malnutrition, had preferences for certain foods like biscuits and gravy, which were not consistently provided in double portions as requested. The resident's representative had communicated these preferences to the facility, but they were not documented on the meal ticket, leading to inconsistencies in meal service. The facility's failure to document and adhere to the resident's dietary preferences contributed to the deficiency, as confirmed by staff interviews and record reviews.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored and labeled properly on two medication carts. Specifically, insulin pen injection devices and inhaler medications were not labeled with open dates, which is necessary to determine their expiration and ensure safe administration. During an observation, a Fluticasone inhaler and a Humalog insulin pen were found without open dates on the 400 hall medication cart. The LPN responsible for this cart acknowledged that insulin medications should be dated when opened to determine when they need to be discarded, and confirmed that the Fluticasone inhaler was not dated, making it unclear when it was opened. On the 500 hall medication cart, a Humalog insulin pen and a Lantus insulin pen were found with open dates that indicated they should have been disposed of, as they were beyond the 28-day usage period. The LPN responsible for this cart confirmed that these insulin pens were only good for 28 days after opening and acknowledged the potential danger of administering expired medication. The DON also confirmed that medications like insulin and inhalers should be labeled with the resident's name and the date they were opened, as some medications are only effective for a certain number of days after opening.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident who required assistance with activities of daily living (ADL). The resident, who was over 65 years old and had diagnoses including dementia, muscle weakness, and anoxic brain damage, was observed multiple times with long, untrimmed, and visibly soiled fingernails. Despite the facility's policy requiring daily cleaning and regular trimming of nails to prevent infections and skin problems, the resident's fingernails were found to be approximately one inch long with dark debris underneath them on several occasions. The comprehensive care plan for the resident, which was revised earlier in the year, indicated a risk for skin breakdown and self-inflicted scratches due to long fingernails. However, the electronic medical record did not show documentation of nail care being provided since early February, despite the resident's need for assistance with ADLs. Interviews with staff, including a CNA and an LPN, confirmed the resident's dependency on staff for nail care and the potential risks associated with neglecting this care. The deficiency was identified through observations and staff interviews, highlighting a lapse in the facility's adherence to its own policies and procedures regarding nail care.
Deficiency in Monitoring and Care Planning for Continuous Glucose Monitor
Penalty
Summary
The facility failed to ensure that a resident with a continuous glucose monitor (CGM) received the highest practicable treatment and care in accordance with professional standards and the comprehensive person-centered care plan. The resident, who was cognitively intact and had a diagnosis of Type I diabetes mellitus, was using a Freestyle Libre 2 CGM. However, the facility did not effectively monitor the frequency of CGM changes, train staff on the use of the CGM, or include the use of the CGM in the resident's care plan. The care plan did not address the use of the CGM, and the physician's orders did not specify the frequency of CGM changes or the requirement for the resident to report blood glucose levels to the nurse. Interviews with staff revealed a lack of training and awareness regarding the CGM. An LPN stated she had not received training on the CGM and was unsure about the frequency of changes, mistakenly believing it to be every eight days. The Director of Nursing acknowledged that the facility should have tracked the frequency of CGM changes and that an assessment confirming the resident's ability to change the monitor independently was conducted late. The DON also admitted that the care plan should have included the use of the CGM, and staff training on the Freestyle Libre 2 was necessary.
Failure to Adhere to Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with professional standards of practice for a resident who required oxygen therapy. The resident, who had diagnoses including dementia, anxiety disorder, lung cancer, chronic obstructive pulmonary disease, and type two diabetes, was observed receiving oxygen at 4 liters per minute (LPM) via nasal cannula on multiple occasions. However, the physician's order specified that the resident should receive oxygen at 3 LPM continuously to maintain oxygen saturation at or above 90%. Despite this, the medication administration record inaccurately documented that the resident received 3 LPM of oxygen. Interviews with staff revealed that the certified nurse aides were informed of the oxygen rates but did not adjust the settings, which were the responsibility of the licensed nurses. A licensed practical nurse confirmed that the resident was receiving 4 LPM instead of the ordered 3 LPM and acknowledged the need to follow physician orders as written. The director of nursing emphasized the importance of adhering to physician orders and obtaining new orders if changes were necessary, highlighting the potential for medical complications if orders were not followed.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pueblo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rock Canyon Respiratory And Rehabilitation Center | 0.2 mi | — | 1 | 0 |
| Lakeshore Post Acute And Rehabilitation Center | 1.1 mi | — | 4 | 0 |
| Life Care Center Of Pueblo | 1.8 mi | — | 2 | 0 |
| High Plains Post Acute Llc | 2.3 mi | — | 0 | 0 |
| Pavilion At Villa Pueblo, The | 4.2 mi | — | 20 | 1 |
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