Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
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 Pavilion At Villa Pueblo, The during CMS and state inspections, most recent first.
A resident with dementia and cognitive decline was not protected from sexual abuse by another resident, as staff failed to document critical details of the incident, did not update care plans or monitor behaviors, and did not confirm or document consent for an intimate relationship. The resident's representative was not informed of the incident or any relationship, and staff interviews revealed inconsistent understanding and documentation of monitoring and consent procedures.
Two residents at risk for skin breakdown did not consistently receive weekly skin assessments as ordered by physicians and facility policy. Review of electronic medical records showed multiple weeks where assessments were not documented, and staff interviews confirmed reliance on paper schedules rather than electronic alerts, leading to missed assessments.
A resident who was dependent on staff for ADLs and had complex medical needs did not receive scheduled showers as required by facility policy and her preferences. Over a 30-day period, documentation showed only two showers were provided, with no records of refusals or reasons for missed showers. Staff interviews revealed inconsistent assignment of shower duties and incomplete documentation, resulting in the resident not receiving necessary hygiene care.
A resident with multiple complex medical conditions did not have physician visit progress notes maintained in the EMR as required, due to the physician's revoked system access and changes in facility procedures for handling medical records. As a result, the resident's medical record was incomplete and not readily accessible to staff.
Failure to Protect Resident from Sexual Abuse and Inadequate Documentation of Consent
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, despite having policies in place prohibiting abuse, mistreatment, and neglect. On the date of the incident, a certified nurse aide observed one resident fondling another resident's private areas in a common area. The facility's investigation did not document critical details such as the specific areas touched, whether the touching was over or under clothing, or include signed witness statements from staff. The investigation also failed to clarify whether the relationship between the two residents was consensual, as there was confusion regarding the identity of the resident with whom the victim had a prior relationship. The resident who was the victim had diagnoses including multiple sclerosis, generalized muscle weakness, and unspecified dementia, with documented cognitive decline and dependence on staff for daily care. The resident's representative stated that the resident would not be able to understand or consent to intimate contact due to her dementia and was not aware of any relationship with the alleged perpetrator. The care plans and medical records for both residents did not contain updated interventions, documentation of behavior monitoring, or sexual consent assessments following the incident. There was also no evidence that the residents' representatives were properly informed or that the care plans were revised to address the incident. Staff interviews revealed inconsistent knowledge and documentation regarding monitoring for inappropriate touching and consent. Some staff believed monitoring was in place, but there was no supporting documentation in the medical records. The facility administrator acknowledged that there was no formal assessment tool for determining capacity to consent to sexual relationships, and the medical director indicated that consent should be obtained from representatives for residents with dementia. However, no such documentation was found, and the investigation relied on assumptions about the residents' relationship without confirming consent or informing the appropriate parties.
Failure to Consistently Complete and Document Weekly Skin Assessments
Penalty
Summary
The facility failed to ensure that weekly skin assessments were consistently completed for two residents, as required by physician orders and facility policy. For one resident with diagnoses including amyotrophic lateral sclerosis, subdural hemorrhage, malnutrition, and dysphagia, the care plan and physician orders specified weekly skin assessments to be documented every Sunday evening. However, review of the electronic medical record revealed that several weekly assessments were not documented during the review period, excluding the weeks the resident was hospitalized. The resident, who was cognitively intact but dependent on staff for mobility and care, was unable to confirm when her skin was last assessed. Another resident, with a history of atherosclerotic heart disease, chronic heart failure, fibromyalgia, muscle weakness, and dementia, also had a care plan and physician order for weekly skin assessments every Tuesday evening. The record review showed that multiple weekly assessments were missing during the review period. This resident was moderately cognitively impaired, required substantial assistance with mobility and hygiene, and was always incontinent of bowel and bladder, placing her at risk for skin breakdown. Staff interviews confirmed that weekly skin assessments were expected and that documentation should occur in the electronic medical record. However, it was noted that nurses appeared to rely on a paper schedule rather than electronic alerts, which may have contributed to missed assessments. Both the regional clinical consultant and nursing staff acknowledged the missing documentation for the two residents.
Failure to Provide Scheduled Showers and Maintain Hygiene for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who was dependent on staff for activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene, specifically by not providing showers according to the resident's preferences and the facility's own schedule. The resident, who had diagnoses including amyotrophic lateral sclerosis, subdural hemorrhage, protein-calorie malnutrition, and dysphagia, was cognitively intact and required staff assistance for toileting, dressing, bed mobility, and transfers. Observations over multiple days showed the resident with greasy, unwashed hair, and the resident communicated that she had not received a shower in about 10 days, expressing a preference for at least one shower every seven days. Review of documentation revealed significant gaps in shower provision and record-keeping. The facility's policy required documentation of showers, refusals, and any interventions, but records showed that the resident received only two showers over a 30-day period, despite being scheduled for two showers per week. There was no documentation of shower refusals or reasons for missed showers in the electronic medical record, and the shower schedule had not been updated to reflect the resident's preferences since before her admission. Interviews with staff indicated that the designated shower aide was frequently reassigned to floor duties, leaving CNAs responsible for showers, but documentation and communication about completed showers and refusals were inconsistent. Staff were aware of the importance of showers for hygiene and skin integrity, but the lack of updated schedules, incomplete documentation, and inconsistent assignment of shower duties led to the resident not receiving showers as scheduled or preferred.
Incomplete Physician Documentation in EMR
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for one resident, as required by its own Charting and Documentation policy and accepted professional standards. Specifically, the physician's visit progress notes for the resident were not maintained in the electronic medical record (EMR) and were not readily accessible. The last physician's visit progress note in the EMR was from April 2024, despite the resident being seen by the physician on multiple occasions after that date. The physician's notes for these subsequent visits were not uploaded to the EMR, resulting in incomplete documentation. This deficiency occurred after the facility eliminated its medical records department and assigned the responsibility of scanning medical records into the EMR to the receptionist. Additionally, the physician's access to the EMR was revoked when he ceased to be the facility's medical director, even though he continued to serve as the resident's primary provider. The physician's EMR access was not reinstated until the time of the survey, which contributed to the lack of timely and complete documentation in the resident's medical record. The resident involved had multiple complex medical conditions, including multiple sclerosis, generalized muscle weakness, and dementia, and was dependent on staff for most activities of daily living.
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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) |
|---|---|---|---|---|
| Pueblo Heights Nursing And Rehabilitation | 1.1 mi | — | 1 | 1 |
| University Park Care Center | 1.5 mi | — | 1 | 0 |
| High Plains Post Acute Llc | 2.5 mi | — | 0 | 0 |
| Center At Park West Llc, The | 3.6 mi | — | 6 | 0 |
| Rock Canyon Respiratory And Rehabilitation Center | 4 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.