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 Pueblo Heights Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with TBI, depression, PTSD, and a history of suicide attempts by gunshot was admitted with hospital orders for suicide precautions, but the facility did not implement suicide precautions or develop a suicidal ideation care plan at admission. Over the stay, the resident repeatedly voiced suicidal thoughts and engaged in self-harm behaviors, including wrapping cords around the neck and attempting to stab the leg with a pen, while NPs and mental health providers recommended one-to-one supervision and restriction of access to cords, utensils, sharps, and other hazards. These recommendations and orders were not consistently implemented, the comprehensive care plan was not updated to include specific safety measures, hazardous items such as cords, pens, cutlery, and broken glass remained accessible, and staff were unaware of the resident’s safety plan and required interventions, resulting in an immediate jeopardy determination for failure to provide necessary behavioral health care and services.
The facility failed to maintain a safe and sanitary environment, with issues such as leaking toilets, broken soap dispensers, and inadequate air conditioning in resident rooms. Hallways had outlets and baseboards coming off the walls, and shower rooms had chipping paint and missing floor pieces. The maintenance assistant acknowledged these issues, stating repairs were ongoing but slow.
A facility experienced a medication error rate of 9.68%, exceeding the acceptable 5% threshold. Errors included an LPN failing to prime an insulin pen and forgetting to administer eye drops, and an RN not notifying a physician about an unavailable medication. Staff interviews highlighted protocol lapses, contributing to the high error rate.
The facility failed to provide residents with food that was palatable in taste, texture, and temperature, as per their policy. Resident interviews revealed dissatisfaction with food quality, citing issues like mushy vegetables, cold meals, and lack of seasoning. Observations showed inadequate food temperatures, and staff interviews highlighted systemic issues in addressing food complaints and maintaining appropriate temperatures.
The facility failed to maintain a sanitary environment, as evidenced by inadequate implementation of Enhanced Barrier Precautions (EBP) for residents with wounds or indwelling devices, improper cleaning methods in resident rooms, and uncovered laundry during transportation. Staff did not consistently use gowns for EBP, high-touch surfaces were not cleaned daily, and laundry carts were not fully covered, exposing clean laundry to potential contamination.
A resident in an LTC facility was not provided with adequate incontinence supplies, leading to a lack of dignity and resident rights. The facility had stopped using reusable incontinence pads, instead using folded bath blankets, which were insufficient for absorbing urine. Staff interviews confirmed the change in policy, with disposable pads reserved for specific cases. The resident expressed frustration and upset due to the inadequate supplies.
A facility failed to assess a resident for safe self-administration of medications. The resident, who was cognitively intact, was observed self-administering pills without a documented assessment or physician's order, contrary to facility policy. Staff interviews confirmed the lack of assessment and care plan inclusion for pill medications, posing a risk due to other residents with dementia on the unit.
A resident with limited mobility due to a stroke was unable to consistently access the bathroom call light, as it was often wrapped around a grab bar near the floor. Despite requiring substantial assistance and having a care plan indicating the call light should be within reach, the resident had to yell for help. The DON confirmed that CNAs should ensure call lights are accessible.
A resident with severe cognitive impairments was not adequately monitored, leading to an incident of sexual abuse against another resident with cerebral palsy and quadriplegia. The facility failed to document assessments or progress notes following the incident, and care plans were not updated promptly. Staff interviews revealed prior instances of inappropriate behavior that were not addressed, highlighting deficiencies in the facility's response to prevent abuse.
A resident with multiple health conditions, including dementia and COPD, did not receive appropriate assistance with ADLs as per her care plan. Observations showed she was often left in a hospital gown, with meals uneaten or eaten with fingers due to lack of utensils, and without adequate personal hygiene care. Staff interviews revealed inconsistencies in care, with the care plan not reflecting her preferences or any refusal of care.
A resident with severe cognitive impairment and specific activity preferences was not regularly engaged in meaningful activities, as required by the facility's policy. Observations showed the resident often left without engagement, and activity records indicated minimal participation. Staff interviews confirmed the lack of activities was due to staffing shortages and language barriers.
A resident at an LTC facility developed a Stage 2 pressure ulcer due to the facility's failure to implement timely interventions. Despite being at risk for pressure injuries, the resident did not receive necessary care such as frequent repositioning or an air mattress. The care plan was delayed, and there were inconsistencies in wound documentation. Staff interviews revealed a lack of awareness and communication regarding the resident's condition and care needs.
A resident with diabetes did not receive proper insulin administration due to an LPN's failure to prime the insulin pen as per manufacturer's guidelines. The LPN acknowledged the error, and the DON confirmed the necessity of priming to ensure correct dosing.
The facility failed to properly store and label medications, as expired medications were found in a medication cart and a Tubersol vial was not discarded after 30 days as required. Nursing staff acknowledged the oversight, and the DON confirmed the need for proper disposal of expired medications.
Failure to Implement Suicide Precautions and Safety Interventions for Suicidal Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including suicide precautions and person-centered safety interventions, for a resident with a significant history of self-harm and active suicidal ideation. The resident was admitted with traumatic brain injury, depression, PTSD, epilepsy, and a documented history of attempted suicide by two self-inflicted gunshot wounds to the head in 2025. Hospital discharge orders at admission included suicide precautions, but the facility did not implement suicide precautions or develop a suicidal ideation care plan upon admission. Baseline care plans for cognitive impairment, psychotropic medications, and safety risk did not include person-centered safety interventions related to the resident’s suicide attempt history or the hospital’s suicide precaution orders. During the stay, the resident repeatedly expressed suicidal thoughts and engaged in self-harming behaviors, while the facility failed to implement ordered or recommended safety measures. On one occasion, staff observed the resident throwing items and stating she wanted to cut herself and die; the NP recommended one-to-one supervision and removal of potential threats from the room, but the facility did not implement one-to-one supervision and loose cords remained accessible. A behavioral health crisis team completed a safety plan with coping strategies and environmental safety measures, including restricting access to cords, utensils, and sharps, yet this safety plan was not incorporated into the comprehensive care plan and staff were not aware of its contents. The comprehensive care plan documented the resident’s history of suicide attempt and chronic suicidal ideation and included general behavioral and emotional interventions, but did not include specific, consistent safety interventions such as continuous supervision or systematic removal of hazardous items. Subsequent events showed ongoing suicidal ideation and self-harm attempts without corresponding safety actions by the facility. The resident was found attempting to wrap cords around her neck and later was seen wrapping telephone and call light cords around her neck and trying to stab her leg with a pen obtained from the lobby, despite prior documentation that threats had been removed from the room. The resident continued to make statements about wanting to hurt herself, including describing digging through her nose to scratch her brain to end her life. A psychologist evaluated the resident and recommended restricting access to all cords, utensils, and sharps, but the care plan was not updated to include these recommendations, and observations showed the resident still had access to pens and cords. The NP ordered one-to-one supervision again later in the stay, but this order was not initiated, and the resident was later observed with cutlery and broken glassware from the kitchen in her room and throwing plates and cutlery. During the survey, the resident was observed unattended near medication carts with accessible pens and with multiple reachable cords in her room, and staff interviews confirmed they were not aware of the safety plan or specific safety interventions, demonstrating the facility’s failure to implement physician and mental health provider orders and recommendations, to assess suicide risk upon admission, and to develop and communicate a person-centered safety care plan. The surveyors determined that these failures created an immediate jeopardy situation because the facility did not provide appropriate support and supervision for a resident with a history of self-harm who had voiced active threats to harm herself. The facility’s own Suicide Threat policy required immediate reporting of suicide threats, assessment by nursing leadership, continuous staff presence with the resident until evaluation, notification of the physician and responsible party, informing all involved staff of the suicide threat, monitoring mood and behavior, updating care plans, and documenting details in the medical record. Despite this policy, the record showed repeated suicidal ideation and self-harm behaviors, multiple external evaluations and recommendations, and two separate NP recommendations for one-to-one supervision, without consistent implementation of ordered or recommended safety interventions, without timely care plan updates to reflect suicide precautions and environmental restrictions, and without effective staff education on the resident’s safety needs.
Facility Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations and resident interviews revealed several maintenance issues in individual resident rooms, including a leaking toilet, broken soap dispenser, lack of weatherstripping on doors, absence of air conditioning, and broken tiles. Residents reported these issues to staff, but repairs were delayed. Additionally, hallway maintenance was inadequate, with outlets and baseboards coming off the walls. The facility's shower rooms also exhibited deficiencies, such as chipping paint and missing transition floor pieces. Wet towels were left on the floor in one of the shower rooms. During an environmental tour, the maintenance assistant acknowledged these issues and stated that repairs were ongoing. The maintenance department was responsible for identifying and addressing these deficiencies, but the process appeared to be slow and reactive, focusing on one area at a time based on severity.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 9.68%, resulting from three errors out of 31 opportunities. The errors were identified during medication administration observations and involved both insulin and artificial tears. Specifically, a Licensed Practical Nurse (LPN) did not prime an insulin pen before attempting to administer insulin to a resident, which is a necessary step to ensure the correct dosage is delivered. Additionally, the LPN forgot to administer prescribed eye drops to the same resident, initially placing the medication in her pocket and only administering it after being prompted. Another incident involved a Registered Nurse (RN) who was unable to administer a prescribed dose of calcium with vitamin D to a resident because the medication was not in stock. The RN documented the unavailability in the resident's progress notes and contacted the transportation coordinator responsible for ordering over-the-counter medications but failed to notify the physician about the situation. This oversight in communication could potentially affect the resident's treatment plan. Interviews with staff, including the Director of Nursing (DON), highlighted the importance of adhering to medication administration protocols, such as priming insulin pens and notifying the physician when medications are unavailable. The DON emphasized that medications should not be stored in pockets due to infection control concerns. These lapses in protocol adherence contributed to the facility's failure to maintain an acceptable medication error rate.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste, texture, and temperature, as per their Food Preparation Guidelines policy. The policy, revised in January 2023, emphasized the importance of preparing foods to preserve or enhance residents' nutrition and hydration status, using methods that conserve nutritive value, flavor, and appearance. However, multiple resident interviews revealed dissatisfaction with the food quality, citing issues such as mushy vegetables, cold meals, repetitive menu items, lack of seasoning, and undercooked or over-spiced food. Observations during a dinner meal preparation and service showed that the cook did not add seasoning to the bell peppers and onions, and the last meal tray was served after a significant delay, potentially affecting the food temperature. A test tray evaluation by surveyors found that the food was served at inadequate temperatures, with the sausage and peppers at 100.4 degrees Fahrenheit and the scalloped potatoes at 119 degrees Fahrenheit. The potatoes were also noted to be dry, hard, and bland, indicating a failure to meet the facility's standards for food preparation. Interviews with the dietary manager and nursing home administrator highlighted systemic issues in addressing food complaints and maintaining appropriate food temperatures. The dietary manager acknowledged receiving complaints about cold food and expressed a desire to encourage more residents to eat in the dining room. However, he was unaware of specific complaints about bland or overcooked food. The administrator admitted that the room tray carts were not equipped to maintain heat for extended periods and was unaware of the availability of plug-in hot boxes. Despite having a performance plan in place, the facility's efforts to address food concerns appeared insufficient, as evidenced by the ongoing resident dissatisfaction.
Infection Control and Sanitation Deficiencies
Penalty
Summary
The facility failed to establish a sanitary environment to prevent the transmission of communicable diseases and infections on two of four hallways. Specifically, the facility did not implement and follow Enhanced Barrier Precautions (EBP) for residents with wounds and/or indwelling medical devices. For instance, Resident #82, who had a Foley catheter, did not have EBP signage or personal protective equipment (PPE) available outside his room, and staff only wore gloves, not gowns, during care. Similarly, Resident #84, who was on EBP, did not have staff donning gowns during wound care, and staff were unaware of the reasons for EBP implementation. The facility also failed to use proper cleaning methods when sanitizing residents' rooms. Observations revealed that housekeepers did not clean high-touch surfaces daily and used the same mop for both bathroom and bedroom floors without treating them as separate areas. This was contrary to the facility's policy, which required high-touch surfaces to be cleaned daily and rooms with two sides to be treated as separate rooms during cleaning. Additionally, the facility did not ensure residents' laundry was appropriately covered during transportation. An unidentified housekeeper was observed transporting personal laundry on a cart that was not fully covered, exposing clean laundry to potential contamination. The housekeeping director confirmed that clean linen and residents' laundry should always be covered during transportation, which was not adhered to in this instance.
Failure to Provide Adequate Incontinence Supplies
Penalty
Summary
The facility failed to ensure the dignity and rights of a resident by not providing adequate incontinence supplies. Resident #25, a 77-year-old with diagnoses including atrial fibrillation, type two diabetes, and muscle weakness, was cognitively intact and required moderate assistance with transfers. The resident reported that the facility had stopped providing reusable incontinence pads, instead using folded bath blankets, which were inadequate for absorbing urine during incontinent episodes. This led to the resident feeling frustrated and upset as her bed would become saturated with urine. Observations confirmed the absence of incontinence pads in the resident's room and the facility's central supply room. Interviews with staff, including the central supply director and a CNA, revealed that the facility had discontinued the use of reusable incontinence pads, opting for disposable ones only for residents with specific needs such as air mattresses or wounds. The director of nursing acknowledged the change in policy, citing concerns about skin breakdown and infections, but was unaware of any specific complaints from Resident #25 regarding the lack of incontinence pads.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed for the self-administration of medications. The resident, who was cognitively intact and had a history of muscle weakness, hypertension, and falls, was observed self-administering a cup of pills left at her bedside. However, there was no documented assessment or physician's order for the resident to self-administer these pill medications, as required by the facility's policy. The policy mandates that a resident may only self-administer medications after an interdisciplinary team assessment and a physician's order. Interviews with staff revealed that the resident had orders and assessments for self-administration of inhaler and nebulizer medications but not for pill medications. The RN and DON confirmed that the resident's care plan did not include self-administration of pill medications, and there was a risk due to other residents with dementia who wandered the unit. The failure to conduct a proper assessment and obtain necessary orders for self-administration of pill medications led to the deficiency.
Inaccessible Call Light for Resident with Limited Mobility
Penalty
Summary
The facility failed to provide reasonable accommodation for a resident's mobility and accessibility needs, specifically regarding the accessibility of the bathroom call light. The resident, a 74-year-old individual with a history of cerebral infarction, chronic respiratory failure, and chronic obstructive pulmonary disease, required substantial to maximum assistance for transfers and bathroom use. Despite being cognitively intact, the resident experienced difficulty reaching the call bell cord in the bathroom due to limited range of motion in the right arm, a result of a stroke. Observations confirmed that the call bell cord was often wrapped around the grab bar near the floor, making it inaccessible to the resident. Interviews and record reviews revealed that the resident had to resort to yelling or banging on the wall to summon help, as the call bell was not within reach. The baseline care plan indicated that the call light should be kept within reach at all times, yet this was not consistently adhered to. The Director of Nursing acknowledged that call lights should be accessible and that CNAs should ensure this when assisting residents in the bathroom. The deficiency was identified through multiple observations and interviews, highlighting a failure to accommodate the resident's needs adequately.
Failure to Protect Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident, which was witnessed by a certified nurse aide (CNA). The incident involved Resident #65, who was seen holding Resident #23's head and rubbing her chest and stomach. Despite the immediate intervention by a licensed practical nurse (LPN), the facility's investigation did not document whether Resident #23 was assessed following the incident or if the abuse was substantiated. Resident #65, who has severe cognitive impairments due to dementia and a traumatic brain injury, was not initially identified as having physical behavioral symptoms directed towards others. However, a care plan addressing his tendency to invade personal space was only initiated after the incident. The facility's records lacked progress notes related to the incident, and there was no documentation of a one-to-one caregiver being assigned to Resident #65, despite staff reports indicating this measure was taken temporarily. Resident #23, who has cerebral palsy and quadriplegia, was also not assessed following the incident, and her electronic medical record (EMR) did not reflect the event. Staff interviews revealed that there were previous instances of Resident #65 getting too close to Resident #23, but these were not adequately addressed. The facility's director of nursing (DON) acknowledged that progress notes should have been documented and that the interdisciplinary treatment team (IDT) met after the incident, but this was not recorded in the EMR.
Failure to Assist Resident with ADLs
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident #13, received appropriate assistance with activities of daily living (ADLs) as per her comprehensive care plan. The resident, who was 79 years old and had diagnoses including lumbar spondylosis, COPD, hypertension, unspecified dementia, and muscle weakness, required partial to moderate assistance with dressing, minimal assistance with transferring, and setup assistance for eating. Despite these needs, observations revealed that the resident was often left in a hospital gown, with meals uneaten or eaten with fingers due to lack of proper utensils, and without adequate personal hygiene care. Observations over several days showed that Resident #13 was frequently found lying in bed in a hospital gown, with her meals uneaten or partially eaten using her fingers, and without proper utensils. Her care plan indicated she required extensive assistance with dressing and personal hygiene, yet she was often uncovered, with her incontinence brief open, and her fingernails were observed to be long and dirty. The care plan did not reflect her preferences or any refusal of care, and there was no documentation of her preferring to stay in bed or wear a hospital gown. Interviews with staff, including a CNA and the DON, revealed inconsistencies in the care provided to Resident #13. The CNA mentioned that the goal was to get the resident dressed and in her chair after breakfast, but the care plan did not document her preference for wearing a hospital gown or staying in bed. The DON stated that morning care should include getting residents out of bed and assisting with personal hygiene, but acknowledged that Resident #13 did not always get out of bed and that her care plan should reflect her preferences. These discrepancies contributed to the facility's failure to provide the necessary services to maintain or improve the resident's abilities in ADLs.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities for a resident, identified as Resident #62, who was dependent and had specific activity preferences. The facility's policy required an ongoing program to support residents' choices based on their comprehensive assessment, care plan, and preferences. However, observations revealed that Resident #62 was not regularly engaged in individualized, purposeful, and therapeutic activities. The resident, who had severe cognitive impairment and required maximal assistance for daily activities, was often left without meaningful engagement, such as music or television, and was not invited to participate in group activities. Resident #62 had a history of non-Alzheimer's dementia, Parkinson's disease, and muscle weakness, and his preferred language was Spanish. His care plan indicated interests in listening to music, being around pets, going outside, and participating in religious services. Despite these documented preferences, the resident was observed sitting in his wheelchair with no engagement or interaction from staff. The facility's activity records showed minimal one-on-one visits, with significant gaps in activity participation over several months, and no documentation of the resident refusing activities. Interviews with staff, including CNAs and the activities director, confirmed that Resident #62 did not participate in many group activities and was not receiving the intended one-on-one visits due to a lack of activities staff. The activities director acknowledged the resident's enjoyment of people watching, one-on-one discussions, and listening to music but cited staffing shortages as a reason for the lack of engagement. Additionally, the language barrier was noted, as the facility did not have a translator, and communication relied on staff who spoke Spanish or used translation pages.
Failure to Prevent Pressure Ulcer in Resident
Penalty
Summary
The facility failed to provide adequate pressure ulcer prevention and care for a resident, leading to the development of a Stage 2 pressure injury on the resident's coccyx. The resident, who was admitted with severe cognitive impairment and was dependent on staff for all activities of daily living, was identified as being at risk for pressure injuries due to immobility and incontinence. Despite this, the facility did not implement timely interventions such as frequent repositioning, incontinence care, or the use of a pressure redistribution mattress, which were necessary to prevent the development of pressure injuries. Observations and interviews revealed that the resident did not have an air mattress, which was recommended by the interdisciplinary team after the pressure injury was identified. The care plan for the resident did not initially include any pressure injury prevention measures, and a specific care plan addressing the risk of pressure ulcers was not initiated until 20 days after admission and six days after the pressure injury was first noted. The facility's documentation was inconsistent, with discrepancies in the recorded size and stage of the wound, and there was no documentation of the family's alleged refusal of the air mattress. Interviews with staff, including the DON and CNAs, indicated a lack of awareness and communication regarding the resident's pressure injury and the necessary interventions. The DON acknowledged that the care plan should have been developed upon admission and that preventative measures should have been in place. The facility's failure to document the family's preferences and the lack of timely implementation of interventions contributed to the resident's development of a pressure ulcer.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. During an observation, an LPN was found to have not primed an insulin pen before administering insulin to a resident, which is against the manufacturer's guidelines. The insulin pen was supposed to be primed to ensure the correct dose was administered and to remove any air that might have collected in the insulin cartridge. The LPN acknowledged the mistake and stated that she had recently received training on priming insulin pens. The resident involved was a 75-year-old with a history of type 2 diabetes mellitus, chronic kidney disease stage three, and a myocardial infarction. The resident was cognitively intact and required assistance with transfers, dressing, and bathing. The incident occurred when the LPN was administering three units of Insulin Lispro as prescribed. The Director of Nursing confirmed that insulin pens should be primed before drawing up the dose to ensure the correct administration of medication.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards. During an observation of the medication cart on the Diamond Way hall, a registered nurse identified expired medications, including a bottle of calcium with vitamin D and a bottle of Fluticasone Propionate nasal spray, which had expiration dates of June 2024 and April 2024, respectively. Additionally, in the East medication storage room, a vial of Tubersol solution was found with an opened date of June 11, 2024, which should have been discarded 30 days after opening, as per the manufacturer's guidelines. Interviews with the nursing staff confirmed the oversight in medication management. The registered nurse responsible for the Diamond Way hall medication cart acknowledged the presence of expired medications and indicated they would be disposed of. Another registered nurse confirmed that the Tubersol vial should have been discarded after 30 days of being opened. The Director of Nursing also acknowledged that expired medications should be discarded and confirmed the Tubersol vial should have been disposed of according to the guidelines.
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Illustrative
What surveyors actually found near you
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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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Illustrative
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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) |
|---|---|---|---|---|
| Pavilion At Villa Pueblo, The | 1.1 mi | — | 20 | 1 |
| University Park Care Center | 1.5 mi | — | 1 | 0 |
| High Plains Post Acute Llc | 3.5 mi | — | 0 | 0 |
| Center At Park West Llc, The | 4.6 mi | — | 6 | 0 |
| Rock Canyon Respiratory And Rehabilitation Center | 4.7 mi | — | 1 | 0 |
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