Inspection Reports for
Atlas Post Acute
2611 JONES AVE, PUEBLO, CO, 81004-2650
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
73% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Dec 5, 2025
Visit Reason
The inspection was conducted to investigate a complaint regarding significant medication errors affecting residents, specifically focusing on medication administration practices for Resident #1.
Complaint Details
The investigation was complaint-driven, focusing on medication errors. The complaint was substantiated with findings of improper medication administration and documentation.
Findings
The facility failed to ensure Resident #1 was administered Midodrine according to physician's orders and parameters, including failure to take blood pressure prior to administration and improper documentation of medication errors. Multiple instances were found where medication was given outside prescribed blood pressure parameters or withheld incorrectly.
Deficiencies (1)
F 0760: The facility failed to ensure Resident #1 was administered Midodrine per physician's orders and parameters. Blood pressure was not taken prior to medication administration on multiple occasions, and medication was administered or withheld outside of ordered parameters.
Report Facts
Medication administrations: 29
Blood pressure checks missing: 3
Medication administrations outside parameters: 21
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding medication administration errors and blood pressure measurement. |
| Director of Nursing | DON | Interviewed about medication administration parameters and staff education. |
| Regional Director of Clinical Services | Interviewed about corrective actions and education related to medication parameters. |
Inspection Report
Routine
Deficiencies: 1
Date: Oct 22, 2024
Visit Reason
The inspection was conducted to assess compliance with regulations regarding the provision of food that accommodates resident allergies, intolerances, and preferences in the nursing home.
Findings
The facility failed to provide food that accommodated resident preferences for three residents (#38, #18, and #23) out of 32 sampled. Specific failures included serving incorrect portion sizes and not providing requested food items such as hard boiled eggs.
Deficiencies (1)
F 0806: The facility failed to ensure each resident received food that accommodated allergies, intolerances, and preferences. Residents #18, #23, and #38 did not consistently receive meals according to their documented preferences.
Report Facts
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Interviewed regarding meal tray accuracy and resident food preferences | |
| CNA #2 | Interviewed regarding food preferences and meal tray accuracy | |
| DM | Dietary Manager | Responsible for obtaining resident food preferences and interviewed about food preference processes |
| RD | Registered Dietitian | Interviewed about resident food preferences and meal ticket accuracy |
| ST | Speech Therapist | Interviewed about resident food preferences and meal ticket accuracy |
| NHA | Nursing Home Administrator | Interviewed about dining committee and staff training related to food grievances |
Inspection Report
Routine
Deficiencies: 4
Date: Apr 30, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, respiratory care, and other professional standards at the nursing home.
Findings
The facility was found deficient in providing adequate fingernail care to a resident, monitoring and training staff on continuous glucose monitor use, ensuring oxygen therapy was administered according to physician orders, and properly labeling medications and biologicals on medication carts.
Deficiencies (4)
F 0677: The facility failed to ensure Resident #32's fingernails were trimmed and clean despite requiring assistance with activities of daily living.
F 0684: The facility failed to ensure Resident #27 with a continuous glucose monitor was monitored effectively, including frequency of monitor changes, staff training, and care planning.
F 0695: The facility failed to ensure Resident #20 received oxygen therapy at the physician-ordered rate of 3 LPM, instead administering 4 LPM without a new order.
F 0761: The facility failed to ensure medications and biologicals were properly labeled with open dates on medication carts, including insulin pens and inhalers.
Report Facts
Residents reviewed: 31
Residents reviewed for fingernail care: 3
Residents reviewed for unnecessary medications: 5
Residents reviewed for respiratory care: 3
Oxygen liter flow ordered: 3
Oxygen liter flow observed: 4
Humalog insulin pen expiration days: 28
Lantus insulin pen expiration days: 28
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Interviewed regarding fingernail care and oxygen therapy |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication labeling and storage |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding fingernail care, glucose monitor, oxygen therapy, and medication labeling |
| DON | Director of Nursing | Interviewed regarding facility policies, staff education, and compliance with physician orders |
Inspection Report
Deficiencies: 16
Date: Nov 2, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including medication self-administration, bed hold policies, PASRR coordination, medication administration, discharge summaries, activities of daily living, range of motion care, fall prevention, pain management, medication error rates, infection control, and immunization policies.
Findings
The facility had multiple deficiencies including failure to ensure proper medication self-administration orders, failure to notify residents of bed hold policies, incomplete PASRR evaluations, failure to monitor vital signs before blood pressure medication administration, incomplete discharge summaries, inadequate assistance with showers, failure to provide range of motion care and splints, incomplete fall risk assessments and neurological checks post-fall, inadequate pain management, lack of consent and evaluation for bed rail use, medication administration errors, incomplete and inaccurate medical records, infection control lapses including hand hygiene and glucometer cleaning, and failure to properly offer and document pneumococcal vaccinations.
Deficiencies (16)
F 0554: The facility failed to ensure Resident #34 had a physician's order and evaluation for self-administration of eye drops, nasal spray, and inhalers at the bedside.
F 0625: The facility failed to inform Resident #85 or their representative in writing of the bed hold policy prior to discharge or transfer.
F 0644: The facility failed to coordinate PASRR assessments for Residents #16 and #32, including missing level II evaluations.
F 0645: The facility failed to submit a PASRR level I for Resident #23 who was admitted with a known major mental illness.
F 0658: The facility failed to ensure Residents #4, #12, and #36 had vital signs monitored prior to administration of blood pressure medications.
F 0661: The facility failed to ensure a complete discharge summary for Resident #86 including a recapitulation of the resident's stay and final status.
F 0677: The facility failed to ensure Residents #14 and #53 received scheduled assistance with showers as planned.
F 0688: The facility failed to provide appropriate care to prevent worsening contractures for Resident #14, who developed bilateral hand contractures without splint use or care planning.
F 0689: The facility failed to ensure fall risk assessments, neurological assessments, and interdisciplinary team reviews were completed for Resident #4 after falls.
F 0697: The facility failed to provide safe and appropriate pain management for Residents #4 and #53, including lack of pain assessment and inadequate pain control during wound care.
F 0700: The facility failed to obtain consent and conduct safety evaluation prior to use of half bed rails for Resident #12.
F 0726: The facility failed to ensure licensed nurses completed competencies in medication math calculations, resulting in a medication administration error.
F 0759: The facility's medication error rate was 7.14%, including failure to verify morphine concentration before administration to Resident #36.
F 0842: The facility failed to maintain secure, accurate, and complete medical records for Residents #85, #23, and #53, including inaccurate discharge documentation, incomplete sleep records, and inaccurate treatment administration records.
F 0880: The facility failed to maintain an infection control program including proper labeling of resident toiletry items, offering hand hygiene before meals, proper placement of wound cleanser, and proper cleaning of blood glucose meters.
F 0883: The facility failed to implement pneumococcal vaccination policies and procedures, failing to offer or document pneumococcal vaccines for Residents #64, #34, #26, #21, and #52.
Report Facts
Medication error rate: 7.14
Pain medication doses: 5
Contracture measurement: 50
Contracture measurement: 25
Baths received: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Administered incorrect morphine concentration to Resident #36 |
| RN #1 | Registered Nurse | Observed performing wound care on Resident #53 |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including discharge documentation, medication administration, and infection control |
| QISC | Quality Improvement Specialist Consultant | Interviewed regarding pain management and infection control deficiencies |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 6, 2023
Visit Reason
The inspection was conducted to investigate complaints of resident-to-resident physical abuse and failure to investigate allegations of abuse at the facility.
Complaint Details
The complaint investigation involved three residents with multiple incidents of resident-to-resident altercations on 4/21/23, 6/23/23, and 8/29/23. The facility failed to investigate these incidents adequately and timely. The director of nursing was the abuse coordinator and investigator but did not confirm substantiation of the incidents. The facility was developing improved investigation procedures.
Findings
The facility failed to prevent resident-to-resident altercations involving three residents and failed to thoroughly investigate allegations of abuse in a timely manner. Multiple incidents of physical altercations between residents were documented, and investigations were incomplete or not provided.
Deficiencies (2)
F 0600: The facility failed to protect residents from physical abuse by another resident and failed to investigate abuse incidents properly.
F 0610: The facility failed to thoroughly investigate allegations of resident-to-resident abuse in a timely manner and failed to respond appropriately to all alleged violations.
Report Facts
Residents reviewed for abuse: 3
Incidents dates: 3
BIMS scores: 14
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Apr 24, 2023
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to residents' rights, environment, and food service.
Findings
The facility was found deficient in ensuring residents' rights to dignity and respect, providing a homelike environment, and serving palatable, safe, and properly prepared food. Residents reported disrespectful staff interactions, lack of personalized room decorations, and poor food quality and temperature.
Deficiencies (3)
F 0550: The facility failed to ensure residents were treated with respect and dignity, including incidents of staff yelling and retaliating against residents. Resident #83 was treated disrespectfully by staff, including a receptionist.
F 0584: The facility failed to provide a homelike environment by not informing or encouraging residents and families to decorate rooms with personal belongings.
F 0804: The facility failed to ensure food was palatable, served at safe temperatures, and accompanied by condiments. Residents reported poor taste, cold meals, and repetitive menu items.
Report Facts
Sample residents: 42
Resident group interview participants: 12
Food temperature - Pureed eggs: 102.5
Food temperature - Pureed cinnamon rolls: 95.1
Food temperature - Eggs: 91
Food temperature - Cinnamon rolls: 82.9
Food temperature - Oatmeal: 120
Food temperature - Milk: 42
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